2 OBER ST - BUILDING INSPECTION IA
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dtivelling
This Section For Official Use Only
Building Permit Numb Date Applied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Fpert�A. res • f 1.2 Assessors Map& Parcel Numbers
1.la is this an accepted street?yes V1.1 no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq tt) Frontage(11)
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?
Check ifyesO Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
/ 2. Owner'gf Reecoy4L AS 6Q� /y)m 0
I9 90
(% Name(Print), City,Stale,ZIP ,,T 1a
.1 Ow Si LV&946-613 ffi1CAe-k- V)CtCd0f1Q10lD
No.mid Street Telephone Email Address Ver-120 .o��
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 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 $ L 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 S 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) ! �j�/ Total All Fees:$
6. Total Project Cos[: $
.J�--� O Check No. Check Amount: Cash Amount:
` 13 Paid in Full 0 Outstanding Balance Due:
r 1
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL'rype(see below)
No.and Street Type Description
U Unrestricted(Buildings up tZ35.000 cu. R.)City/Town,State,ZIP R Restricted 1&2 Famil DweM MasonryRC Roofin CoverinWS Window and SidinSF Solid Fuel Burning Applian
I Insulation
"Tole hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Nome 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
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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or AudWized 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.a 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.eovldns
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 S.ULE.N1
PUBLIC PROPERTY
DEPAM. PENT
KJlalillY O•fM'.w
Vwroa r 7a yr�wuw�or.sr•yaT•s�riar,wsuoRsim ON•0
h19'L71S-9S"•F.47L 9'3-7469646
HOMEOWNER LICLNSE EXEMPTION
Plesw "I
Dat@ S Gl I
Job Loeaum a ��� s% �� l /Y) 1g
Home Owner Address AZ -:!5A Lem
Horne 0wasr Telapbone
Present Mailing Address 9 D Afg— T 6A Ln°M ✓Vl
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or lays and to allow such homeowners to engage an individual for
hire who,does not possess a license,provided that the owner act@ as supervisor.
DFYIN ION OF HOMEOWNER
Persons)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
Permit.
The undersigned"homeownee 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 and requirements and that he/she
Mill comply with said procedures and requirements.
HOMEOWNERS SiGYA RE
APPROVAL OF BUILDING PECTOR
See other side for state code