8 N PINE ST - BUILDING INSPECTION The Commonwealth of Massachusetts
UlfOF
Board of Building Regulations and Standards CITY M
Massachusetts State Building Code, 780 CMR SA Revised Mar Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
��/I g PP P
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
M ,ie ✓� L„rr�z ((mac
Building Official(Print atm
Name) e Date
SECTION 1: SI INFORMATION
1.1 PropeRl ylAddress: 5 �_ 1.2 Assessors Map&Parcel Numbers
� Pt I�,e
1.1a 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'
2.1 Owner of Record:.
f LJMt
Name(Print— ) I City,State,ZIP
ee N, Pier ft 611-Lfp-&?ao {tb,ltw.�[� y.•.4;1 .�ov�
No.and Street Telephone Email A ress
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of UnitsZ Other ❑ Specify:
Brief Description of Proposed World: W .aw
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 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 $ 2. Other Fees: $
4. Mechanical (BVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
i Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ gDo0. 0 Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
- List CSL Type(see below)
Type Description
No.and Street
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
Cityfrown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
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
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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my n#tne below,I hereby attest under the pains and penalties of perjury that all of the information
Icontained ' is a ' ation is true and accurate to the best of my knowledge and understanding.
\V/ ,05A
^nt ner's or Authorized Agent's Name(Electronic Signature) Date
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.mass.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"may be substituted for"Total Project Cost"
CITY OF SAt. -M
PUBLIC PROPERTY
DEPARTPmENT
u OWfY eti.r•.r i
.VAYd 130 W"WOC1OW slfaar f&MAK.VAYADK SCM 019-0
i1L 0 FAX f'L7�9W
HOMEOWNER LICENSE EXEMPTION
Piles"Print
Date
Job Location'
HomoOweerAddtlw Ss A/. r r S-F w aWa t 97
Homo Ownsr Telephone fo t -7 - Y 97b - G 4--�
Preset Mailing Address �;Lo c=
The current exemption of"Homeowners"was extended to include ownw-occupied
dwellings of two Units or lea and to allow such homeowners to engage an individual for
hire who.does not possess a liemse provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Person(s) who owns a parcel attend on which hdshe resides or intends to reside, on
which there is; or is intended to bs, a one or two family dwelling, attached or detached
structures accessory to such use and/or farm 3Wxtura. 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
OillciaL that he/she be responsible for all such work performed under the Building
Permit
The undersigned"homeowner"usumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner'certifies that hetshe undentands the City of Salem
Building Department minimum inspection procedures and requirements and that hdshe
Will comply with said procedures and requir
H0.IEOWNER$ SIGNATLRE
.APPROVAL OF BUILDING 04SPECTOR
See other side for state code
CITY OF S,U,&`i, Aiss,kcjjUSETi"S
13LLIDLNG DEP.IMELST
I20 WASHNGTON STREET, Yo FtoCR
Ttn. (978) 74S-9s9s
KIMBJERLEY DIUXOLL FAX(978) 740.9846
,MAYOR N0-%(,U ST.PIER"
DfUcrait OP pLSUC PIIOPeitTY/stancVG CO\L\IISSIONEIt
Construction Debris Disposal Aftldavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780
Debris, and the provisions of MOL o 40, S 34; CMR section 111.S
Building Permit # is issued with the condition that the dcbris resulting from
this work shall be disposed of in a properly, licensed waste disposal facility as defincd by MGL c
111, S I SOA.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
name of racilfty) .
(iddrnf oYf�cihty)
"dairure ofpermrt ipp6unt
:.ace