171 MARLBOROUGH RD - BUILDING INSPECTION (3) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
\' This Section For Official Use Only
Building Permit Number: Date Applied:, I
(a "(Li
Building Official(Print Name) V >*ature Dale
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
It-1 1 V, Yp o � b.�r,,a --NZ A
i.l a Is this an accepted street?yes L.- no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use - Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Zone: _ Outside Flood Zone?
Private❑ Check if yes[] Municipal fin site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Name(Print) City,State,ZIP
1 :1 1 rnArr l �p —TL 7k- 979-VI;Y�j
No.and Street v Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) Grf Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work': rrtaK� �X_ r,,p .c
U A 14 4c-t_o„ �� � i ._. r\tw �v n-4 c�• u i nt w `TLcc.r cfocr-
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ Db 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ j 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees:$
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
C
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted Buildin s u to 35,000 cu.ft.
City/Town,State,ZIP R Restricted 1&2 Famil Dwellin
M Maso
RC Roofin Coverin
INS Window and Sidin
SF Solid Fuel Burning Appliances
Tele hone I Insulation
Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Regis t Name HIC Registration Number Expiration Date
No.and Street
Email address
Ci /Town State,ZIP Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 25C(6))
Workers Compensation Insurance affidavit must he 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...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
�� 1 _ �� �'t < � � I t2
Print Owner's Name(Electronic Signature) -----
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
to
in this applliicaation is true and accurate to the best of my knowledge and understanding..
�.ErC c�� YQ n
Print Owners or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. An 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 can be found at
www.mass ov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage,finished basement/attics,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"may be substituted for"Total Project Cost"
CITY OF S-UX—NI
PUBLIC PROPERLY
DEPART1LENT
wavat+*r ossmu
rn.1'0.7+s-ss"•FAX/78.740904
HOMEOWNER LICENSE EXEMPTION
Pfew tMtat
Date
Job Location 1 ? 1 m. o Qj r c)S j
Home Owner Address 12 o r L c
Home Owner Telephone 17- 7 k- 7 �7- 9 n
Present Marling Address t I yn lA /C I b o r O 4 C t1 1
The current exemption of"Homeowmew"was extended to include owner-occupied
dwellings of two Unite or lea and to allow such homeowners to engage an individual for
hire who,does not possess a licenses provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Persons)who owns a parcel of land on which he/she resides or intends to reside.on
which thers is, or is intended to be,a one or two family dwelling, attached or detached
structures accessory to such use and/or farm structures. A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official,on a form acceptable to the Building
Official, that he/she be responsible for all such work performed under the Building
Permit
The undersigned"homeowner"assumes responsibility for compliance with the State
Building Code and other applicable by-laws and reguladons.
The undersigned "homeowne"certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATUR ai
APPROVAL OF 13UILDING DiSPECTOR
See other side for state code
i CITY OF S.U.&m. iA-kSSACHL'SETTS
BUILDING DEPARTMENT
• a• 120 WASHINGTON STREET, 3to FLOOR
�'a r TEL (978) 745-9595
FAX(978) 740-9846
KIJIBF-RLEY DRISCOLL
MAYOR THobtAS ST.Pmm
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONMaSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeLribly
Name (Busines&Organi:atimuindividual): G n e r G C�
Address: N'l \ `mwtZ 6(1— �2
City/State/Zip: c e } mA s< Phone #: < 7 c�7 c
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ I am a general contractor and l 6. ❑New construction
employees(full and/or part-time).* have hired the subcontractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet.: 7• [3-Retnodeling
ship and have no employees These subcontractors have 8. ❑ Demolition
working for me in any capacity. workers'comp.insurance. 9, ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
re ed.] officers have exercised their 10.❑ Electrical repairs or additions
3. am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. C. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.)t employees.[No workers' I3.❑Other
comp.insurance required.]
•Any applicant that checks box a] most also GII our the section below showing their workers'compensation policy infurmation.
t I btmeuwren who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new alrdavil indicating such.
'Contractors that check this box most attached an additional sheet showing the name of the subcontractors and their workers'comp.put icy information.
I um an employer that it providing workers'c'ompensadon insurance for my employees. Below Is the policy and Jab site
information.
Insurance Company Name:
Policy 4 or Self-ins. Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cerrt jy under the pains and penalties of perjury that the information provided above is true and correct.
Phone x: C!
Official use only. Do not write in this area,to be completed by city or,town official
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: ____._ Phone#: