15 MAY ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
O uy Massachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct,Repair, Renovate or Demolish a
One-or Two-Family Dwelling
This Sect on z
WT For Official
Building Permit Numb
4
!Building Officiak,(Pri
nt: am
1.1 Property A Ts:b 5-2��4= 1.2 Assessors Map& Parcel Numbers
1.1 a Is this an accepted streeb yes_-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 Provided
I - EttEE!ff Required
E I
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: LS Sewage Disposal System:
Zone: Outside Flood Zone? Municipal 0 On site disposal system 13
Public 0 Private 0 Check if yesD
7
;.SECTION 2:jPROPERTY,OWNER
11� �Own rr ofR N or d.
f_
,,,
Name(Print) City, tat P,
No. an Street Telep one Email Address
p
S C �ek.all fhat,�.a ply)
Addition 0
New ConsEtructionol Existing Building 0 Owner-Occupied Repairs(s) Alteration(s) 0
Number
Units_
Demolition 0 Accessory Bldg, EJ Number of Units Other 0 Specify:
Brief Description of Proposed Work : 0'C
777777-7777-77-7777-77777�7.
SECTION A ,ESTIMATED 4,
Estimated
Costs:
Item
(Labor and Materials)
1. BuildingButldq diokehoWfe isdetumine&,
W
2. Electrical $
01TbIal'Trojedt Cost' X,
3. Plumbing IJ,Qtnpr'
j
4. Mechanical (FrVAQ $ Ls
5. Mechanical (Fire
'To6a1Al1 Fees
Suppr ssion)
Check Nd. Check e6k Amount Cash Amount
:7777:7�
6. Total Project Cost: $ 6 aw-000 Paid i"hfblL_
'x0,Outstanding Due
, r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No. and Street Type 'Descriptioh
U Unrestricted Bd in s up to'35,000 cu. ft.) -
City/Town, State,ZIP R Restricted I Family DwellingJ
M Mason T
RC Roofg Covering
WS W' dow and Siding
SF olid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Re e HIC Registration Nu er Expiration Date
gigtra am
No. and Street
Email address
City/Town, State,ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 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 ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
[, 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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby atte t under the pains and penalties of perjury that all of the information
contai m is ap ication ' true urate to the best of my knowledge and understanding.
Xrint—Owner's or Authorized Agen r e(Electronic Signature) Da
NOTES:
I. 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.rnass.gov/oca Information on the Construction Supervisor License can be found at www.mass.<gov dos
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"maybe substituted for"Total Project Cost"
d
CITY OF SM.E.Nl, N-LuSACHLSETTS
• BUI NG DEPARTNIENT
N 130 WASHINGTON STREET,3° FLOOR
TEL. (978) 745-9595
FAx(978) 740-9846
KIN{gFRt FY DRISCOLI
MAYOR THo%w ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDLVG CONLMIISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
Vim ,
(nam e of hau er)
The debris will be disposed of in
(name of facility)
(address of facility) -
signature-of permi cant
da
dcbtisat drw
CITY OF S.U.E%f
PUBLIC PROPERTY
DEPART'NIENT
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HOMEOWNER LICENSE EXE.ti MON
PIeW Fri�t
Date c�
Job location
Home Owner Address _
Home Owner Telephone
Present MailingAddtese S
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Unite or leas and to allow such homeowners to engage an individual for
hits who does not possess a Haase provided that the owner acts as superviaor.
DEFINMON OF HOMEOWNER
Person(s)who owns a petal of Lmd on which hatshe resides or intends to reside, on
which there is, or is intended to be,a one or two &milt'dwelling, attached or detached
structures accessory to such use and/or farm structures. A person who constructs more
than on@ home in a two year period shall not be considered a homeowner. Such
"lwmeownce shall submit to the Building Official,on a form acceptable to the Building
Otllci4 that hedshe 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 bylaws and regulations
The undersigned "homeowner certiRa that hdshe understands the City of Salem
Building Department minimum inspection procedures and requi rnu and that hdshe
will comply with said procedure r uir ens.
HOMEOWNERS SIGYATLRE `
APPROVAL OF BUILDING INSPECTOR
Sce other side for state code
s ' Bus ingsTr
o FRIEND LUMBER
29 Gibso6 Street • P. O. Box 149 • Medford, MA 02155
617/391-8200 ,
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