14 MOULTON AVE - BUILDING INSPECTIONr
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The Commonwealth of Massachusetts
l r Board of Building Regulations and Standards I't IIZ
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�.' Massachusetts State Building Code, 780 CMR, 7"'edition I SI[
Building Permit Application To Construct. Repair. Renorate Or Demolish a Rei ds,d,1akuun,
One- or Tun-Family Do cllin,G
'y(\ This Section For Official Use Only —
Building Permit Nut CCDate Applied: ,Cn Cad
Signature:
Building Cununisshme0 Inspector of Buildings Date
a
SECTION I: SITE INFORMATION
1.1 Prop,eserty :address: 1.2 Assessors Map & Parcel Numbers
r'a l�Cn
1.Ia Is this an accepted street?yes ✓ no Map Number Parcel Numher
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use I_cr yea (sq fit Fmnta__ M,
1.5 Building Setbacks (ft) --
� Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
i
1.6 Water Supply: (M.G.L c. 40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Munici al On site dis posal system ❑
Public Private❑ Check if yes❑ P' I Y
SECTION 2: PROPERTY OWNERSHIP[
2.1 Owner[of Record:
NaipqP rind Address for Service:
nature Telephoner
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction �ALessory
Aleration(s) ❑ Addition ❑
Demolition ❑ Bldg. ❑ Number of Units Other ❑ Spccify:
Brief Description of Proposed Work: —
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building $ L 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:
4. Mechanical (HVAC) .$ List:
5. Mechanical (Fire S
Total All Fees: $
Suppression)
Check No. Check Amount: Ca,h Amount:___
1 o. Total Project Cost: $�/ 00 0 Paid in Full 0 Outstanding Balance Due:_____J
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Iapir:uiun Date
Nuntc of CSL- Ifolder
List CSL Tcpe(see below) _
\ddrrss l c Description
L L'nrestncled lu,lu 35.000('tl- Fl.i
R Restricted 1&'_ FamiFl Dssrlhne
Signatutrc 1vl :blasonrs' Only
RC Residrnlial Roulin Cos Grin_
Tclrphonc \\'S itesiJr:trial \VinJetc ,md S1duiy -_
SF IZcs ideuti:d Solid Furl Burning \ 1111anLc histall:aims
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or FIIC Registrant Name Registration Number
Address
Espirntiun 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
gOR, CONTRACTOR APPLIES FOR BUILDING PERMIT
1, -�f'�s�V"� �P 0 _, as Owner of the subject property hereby
authorize to act on my behalf, in all mutters
relative_ t work authorized by this building permit application.
f Y,6- L= ------ --- — -�v -- -- --
Signature of Ow__ner Date
SECTION 7b: OWNEW OR AUTHORIZED AGEN T DECLARATION
11, /✓IOd`P� , as Owner or Authorized Agent 7declarethat the statements and information tin the foregoing application are true and accurate, to the best of m
behalf.
—
-
PrintNam�f /-
/,L/,
Signs fif{Gc6El f Owner or Authorized Agent Date
(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. I42A. Other important information on the HIC Program and
Construction Supervisor Licensing (CSL) can be found in 730 CMR Regulations 110.116 and 110.R5, respectively.
2, When substantial work is planned, provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/anics,decks or porch)
Gross living area (Sq. Ft.) Habitable room count _
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths _-.—
Tvpe of heating system Number of decks/ porches
Type of cooling system Enclosed Open _
3. "Total Project Square Footage'• may be substituted for "Toml Project Cost-
CITY OF S.UX.M
PUBLIC PROPERTY
DEPARTMENT
V.ww. - - .130 WADUNG + M S7ncaT•SAtn{SIMSAC MEm 0197e
TO.9'L74S-9S"0 F,x 97L746,944
HOMEOWNER LICENSE EXEMFnON
Please Print
Date
Job Location /L 14ou/10// Ok�Ve SOME tile, o/970 S'A
Home Owner Address 1q ,Glnui4og a rir° Sn/CAM ,resin 0/470
Home Owner Telephone 278 7S� sos 8
Present Mailing Address � cks a a)y-�e
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.
DEFINTfION OF HOMEOWNER
Person(s)who owns a 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 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
Pemrit
The undersigned "homeowner"assume 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 reWoiz�-4�
irements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code