57 MEMORIAL DR - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards OFSALEM
CITY
Massachusetts State Building Code,780 CMR, 7'' edition Revised January
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, 2008
One-or Two-Family Dwelling
This Section F 017ficial Use Only
Building Permit Number: Date Applied: `
Signature: `...,'. �...` ( to
Building ommissioner/Ins uildings Date
ACTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
4 7 11i/EMo2(4C_ -Dal'vr-
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 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❑ Private ❑ Zone: Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP' w`
2.1�0yner'of ecord: -
Name(Pr Address for Service:
Si ature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK' (check all that apply)
New Construction ❑ Existing Building: Owner-Occupied ❑ Repairs(s)X I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs:Labor and Materials Official Use Only •.
1. Building $ ®pp 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost' (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ h
4.Mechanical (HVAC) $ List: /
5. Mechanical (Fire $
Suppression) Total All Fees: $
O d� Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
i'
SECTION 5: CONSTRUCTION SERVICES
51 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name orCSL-Fielder List CSL Type(see below)
Address - - Ty Description
U Unrestricted(up to 35,000 Cu.Ft.)
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC Residential RoofingCovering
Telephone WS Residential Window and Siding
t SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC 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...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, O O , as Owner of the subject property hereby
authorize to act on my behalf, in all matters
relative to work an s b i i permit application.
Si nature O ner Date
SECTION`7b: OWNER' OR AUTHORIZED AGENT DECLARATION
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.
D Z
Print Na /)� p
Signatur fOwn- or nth ri d Agent Daie��— �O /
(Signed under the pains and penalties of perjury)
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and 110.R5, 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
3. "Total Project Square Footage" may be substituted for"Total Project Cost"
ol 1
,y CITY OF SALEM
; low,
PUBLIC PROPRERTY
DEPARTMENT
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IFI:978.74.+-9 95 ♦ l°.%x:978-740.9846
Construction Debris Disposal Affidavit
(required fur 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
I11. S 150A.
The debris will be tr• nsported by:
I name of hauler)
The debris will be disposed of in
- . .-__. -
(name of aci ity)
(address id facility)
ignat a of •nnn applicant
date
b :4
CITY OF $.3LE.%Vi
PUBLIC PROPERTY
DEPARTMENT
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HOMEOWNER LICENSE EXE.KPTIO�N
pies" print
Date Z,-, —
Job Loeatiea
j'7
Horns Owner Addresd /3 Tri✓!�� s a Pe r �e
Hong Owner Telephone 9 7 F 3 S 7 9D 7
Presses Mailing Address
The current exemption of"Homeowners"was extended to include o an individual for
dwellings of two Units or less and to allow such homeowners to engage
hire who.does not posses a license,provided that the owner sets as supervisor.
DEFINMON OF HONMOWNER
Persons) 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 farm structures. A person who constructs more
than one home in a two year period shad not be considered a homeowner. Such
••homeowner"shall submit to the Building Official.on a form acceptable to the Building
Official. that hdshe 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 regulations.
The undersigned "homeowner'certifies that he/she understands the City of Salem
Building Department minimum inspection procedures andf=ujrerrtents and that he/she
will comply with said procedures and requir
HOMEOWNERS SIGNATURE
.APPROVAL OF BUILDING INSPECTOR
See other side for state code