6 OLD RD - BUILDING INSPECTION o--_ _
The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
�� Massachusetts State Building Code, 780 CMR, 7'"edition Building Dept
Building Permit Application To Construct. Repair. Renovate Or Demolish a
One- or Tiro-Fumifl-Duelling
�( \ is Section For Official Use Only
\f Building Permit Number: Date Appl
Signature:
Building Commtsst ner/ spectar of Bud i Date
SECTIO 1:S E INFORMATION
1.1 Property ddress: 1.2 Assessors Map dt Parcel Numbers
6O/ �� S�/10„t Na'�
Ma Number Parcel Number
1.1a Is this an accepted street'?yes ✓ no P
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(tt)
1.5 Building Setbacks(ft)
Side Yards Rear Yard
Front Yard
Required Provided Required Provided Required Provided
1.6 We r Su ly:( G.L c.40,154) 1.7 Flood Zone information: 1.8 Sewage Disposal System:
Zone: — Outside Flood Zone? Municipal O On site disposal system O
Public❑ Pr vate❑ Check if yesO
I SECTION 2: PROPERTY OWNERSHIP'
.1 'ofR or
ell o ora
( i Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(cheek ell that apply)
New Construction D Existing Building❑ Owner-Occupied O Repairs(s) O 1 Alteration(s) ❑ Addition D
Demolition O Accessory Bldg. O 1 Number of Units_ Other O Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Ofllclal Use Only
Item Labor and Materials
I. Building Permit Fee: f Indicate how fee is determined
I. Building S :
❑Standard City/Town Application Fee
2. Electrical S O Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees:.S
4. Mechanical (HVAC) S List:
t .Mechanical (Fire S Total All Fees: f
Suppression)
Check No. _Check Amoune Cash Amount:_
!� 6. Total Project Cost. S 0 Paid in Full 0 Outstanding Balance Due:
r
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number E.apiraoon Date
N.4mc ul'CSL- Hpldcr
a Lut CSL Type Iscc bcluw)
Address
' 9DResidential
Descn t"n
nrestricted u to 35.000 Cu. Ft.)
Signature estricted 1&2 FamilyD%ellin
ason Only
esidential Roofing Covering
Telephone esidential Window and Siding
esidential Solid Fuel Burning Appliance Installation
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. 152.1 2SC(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.
Signe3tAffiqavit AI hed? Yes .......... O No........... O
Zaw
N UTH RIZATION TO BE COMPLETED WHEN
N R ON CTOR APPLIES FOR BUILDING PERMIT
Oi� as Owner of the subject property hereby
to act on my behalf,in all matters
rt ri d this building permit application.
X\ !� Z ewS Date
ECTION 76:OWNEW 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.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of per 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 MW 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 IO.R6 and I IO.RS, respectively.
2. When substantial work is planned,provide the information below
Total floors area(Sq. Ff.) (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
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 SALE.M
PUBLIC PROPERTY
DEPARTMENT
KJMMAL n Dawn
Vwroa
130wA"NGra+snm•sMA,r,MwssMoRssrrs 01970
TEL r,8-74S-9S" • F.Ax 9711-740-994
HOMEOWNER LICENSE EXEMPTION
Please Print
Date Zoo5
Job Location d old �ul >4 �s•'^_ /vl A' o/f 70
Homy Owner Address (o o/ S'w/k� .vet 0/970
Home Owner Telephone 617 o 0
Present Mailing Address G a0 Se .•Z ,44 o/f 7o
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.
DEFINITION 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
Permit.
The undersigned "homeown%DNSPECTOR
lity for compliance with the State
Building Code and other apations.
The undersigned "homeown derst ds the City of Salem
Building Department minimand uirements and that he/she
will comply with said proced
HOMEOWNERS SIGNAT
.APPROVAL OF BUILDING
See other side for state code