38 MEMORIAL DR - BUILDING INSPECTION Z The Commonwealth of Massachusetts
,�� Board of Building Regulations and Standards CITY
V !y ;/ Massachusetts State Building Code, 780 CMR, 71h edition OF SALF.M
•� !-✓ Revised Jamtury
Building Permit Application To Construct. Repair, Renovate Or Demolish a l• ;008
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number• Date Applied:
\. Signature: !^✓ '°"" `�/��
Building Commissioner/InsKc1or of Buildings Date
SECTION 1:SITE INFORMATION
I.I Pr?pasty Address: ,, 2 1.2 Assessors Map& Parcel Numbers
'S X MMp�trA J
L l a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq Il) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Rrquired 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:
Zone: _ Outside Flood Zone?
Public❑ Private O Check if es0 Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 R"ert of Record:
a c 3,y njewlOyGt*( 1>r4
Nume(Psi t Address for Service:
) 7g .7vC 7101
Signatuic Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Pr posed Work:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (BVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
Check No. Check Amount: Cash Amount:
L� 6. Total Project Cost: S 13 Paid in Full 0 Outstanding Balance Due:
r
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL-I lolder I.isi CSL Type(see below)
.r pe Description
Address U UnrestricteJ u to 35,000 Cu.Ft.
R Restricted I&2 Family Dwellin
Signature M M Only
RC Residential Roaring Covering
Telephone WS Residential A�Window andSidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
IIIC Company Name or IIIC Registrant Name Registration Number
Address Expiration Date
Signature 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...........0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 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.
Shmature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
yr ���/ ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print
Signature off Owner or Auth Ized Agent Date
(Signed under the pains and penalties of 'u
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 no.1 have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115,respectively.
2 When substantial work is planned,provide the information below:
Total floors 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
}. "Total Project Square Footage"maybe substituted for"Total Project Cost"
CITY OF SALE.%vf
PUBLIC PROPERTY
DEPARTMENT
KANOAUNDAMA ,
WYOe 130WA*awcrM9ruw Auu Ww=AonLsrmo19'0
9'5-715-9S"9 F.ut 9'6-740.9e46
HOMEOWNER LICENSE EXEMPTION
Phease Print
Date
Job Location //'t ru/t-
Home Owner Address Ssg m e
Home Owner Telephone �-2 -7 8" 7 v t ,1 f�o
Present Mailing Address _ xda
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or less and to allow such homeowners to engage an individual for
hire who does not possess a license,provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Person(s) who owns s parcel of land on which he/she resides or intends to reside, on
which there is, or is intended to be, a one or two family dwelling, attached or detached
structures accessory to such use and/or faun 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"ass ones responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner"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 SIGNATURE ,
,APPROVAL OF BUILDING INSPECTOR
See other side for state code
�A CITY OF SALEM
PUBLIC PROPRERTY
�- DEPARTMENT
\I J 'N 1_'C �.�+1 II\�. tv llMkCr �5.111\I, \h\+i.11 III J
I'rt:'�ry•N�•')3'�! � 1 \x:v7s•NS'ts+e
Construction Debris Disposal Aff7davit
(required fur all demolition vtd renovation work)
In accurdance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, •end the provisions of MGL c 40, S 54;
Building Permit p is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed `vane disposal facility as defined by MGL c
I 11. S 150A.
The debris will be transported by:
Inartte ut•hauler)
The debris will/bee/disposed of in
74-"5 PF.tL
inaawuf aollty)
plddras ul'I':uility)
+Ignatwe of Iwrmlt�pphcanl
date �