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5 MALL ST - BUILDING INSPECTION The Commonwealth of Massachusetts CITY Board of Building Regulations and Standards OF SALEM Massachusetts State Building Code,780 CMR,7'edition Revised January Building Permit Application To Construct,Repair,Renovate rDemolish a 1, 2008 One or Two Fa ell } `, is Se Flu t iaf my , Buililmg)'?etfiitNumber: efa ied ;"r ',Signatttre ate Bwiding Commtsswnerl Insp , ofBml s` I2 1.1 Property�ddr ` 1.2 Assessors`Map&c Parcel Numbers /+ J Map Number -Parcel Number 1.1 a is this an accepted street?yes_ no 1.3-Zoning Information: 1.4 Property Dimensions: Zoning District, - - Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) oil Front Yard Side Yards Rear Yard - R Provided Required Provided Required Provided Required 1.6 Water Supply:(M.G:L c.40,§54) -1.7_Flood Zone Information: 1.8 Sewage Disposal System: Zone: — Outside Flood Zone? Municipal❑ On site disposal system ❑ Public❑ Private❑ - Check if yes❑ , �$EC1'lOIV�"=PRt�,y�n,'RT� �'NERSHI�' 2.1 wn/er of Reco d: �/ S - - Name(Print) :.Address for SGe�rvice: _ Signature Telephone .. ) SE77 CTION 3 I1ERIPT[QPFr12f1'OS7 �V©Rl£= e a(chek- ll that apply New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': < 4. TiP r� o0 SECTION I. EST;IMATVD CONSTRUCT{ON,C()$TS Estimated Costs: OffiataliUse;Only Item Labor and Materials 1.Building $ ] Bud, ing P ertg rt Fee $ Indicate h ow fee is determined: Statidatd Cit}noaam A �l hhbatton Aee 2.Electrical $ TotaTRroleaNt os ,( em 6� mt}ahPlier x 3.Plumbing $ r' ?lP ,xk t F` 4.Mechanical (HVAC) $ wr 5.Mechanical (Fire $ Total Ali Fees Su ression t heek,3lo Check 4mguut: Cash Amount: 6.Total Project Cost: $ p Pmd=in full E1 Outstanding Balance Due:- 7 boo. 'SEC1:ICafNFS �Gb1Y5T1tU;GTIt ;3_FsRUIC�S 5.1 Licensed Construction Supervisor(CSL) "7 4e-77 M ' if L CA-if License Number Expiration Date Name of CSL-Holder List CSL Type(see below) y Pllt i.y00 DU tion Address U Unrestricted(up to 35,000 Cu.Ft. R Restricted t&2 Family Dwelling Signature T M Masonry Only RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation. D Residential Demolition 5.2 Re istere H to I provement Contract r C) Inc Corytyen Name or C Reg t to Registration]Number Address, n —` ��J� .�,� � `. J y� G ��._�(��¢3(Z Expiration Date Signature vim �e+� i T—el/ephone l j SECTION 6 WORT{i RS'COlC3PENSA1ICiLV INSURANCE AFFIDIA�Fr:(M.G:L.e.152.§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes .......... No...........❑ SFC PION 7a:=OWN1zIf ATJTIIORILAIiION+, F'.�1 S >i 11 W=HIi,N OVSNER'SAGE1iIT.OR4ON1$KCT6R'AY.PTS/F(7`RBiII) PERMIT. 1 .-� Grc_ �jJ 16 .! as Owner of the subject property hereby author to act on my behalf,in all matters relative to work authorized by this building permit application. Si nature of Owner Date SE?CT1b)N 71t,£IWJ 4X11> 2RD ACrEI;T IaEC A1R=ATION:. I � A A ,as Owner or Authorized Agent hereby declare that the statements and informatio on the foregoing application are true and accurate,to the best of my knowledge and behalf. M ! c (a!t r L S Print Name ' /.l �Z Signature of Owner or Authorized gat Date Si ned under the pains and enalhes of u r�103F 1. ryAn Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively. 2. When substantial work is planned,provide the information below: Total floors area(Sq.Ft.) (including garage,finished basementlattics,decks or porch) Gross living area(Sq.Ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system " Number of decks/porches Type of cooling system Enclosed Open 3. " "Total Project Square Footage"maybe substituted for"Total Project Cost'