7 OSBORNE - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
d Board of Building Regulations and Standards CITY
r• r^ Massachusetts State Building Code, 780 CMR, 7"edition OF SALEM
Revised Jams<u v
Building Permit Ap licati0n To Construct, Repair, Renovate Or Demolish a 1f/, ' f/y
One-or Tiv -Funnily Dwelling
This Se Lion For Official Use Only
Building Permit Numb Date Applie // , � 77 _ o
Signature: 11 w 1���L t (
Building Commissioner/In. •t rof Buildings Date
ECTION 1: SITE INFORMATION
I Propert y Address: 1.2 Assessors Map& Parcel Numbers
L I 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(sy ft) Frontage(R)
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:
Zone; Outside Flood Zone?
Public❑ Private ❑ ? _ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OV
JNERSHIP'
2.1 O rt of�f ord:
' fit ' �- s r r S ?D,2 S -
Name(Pnn Address for Service:
/ 50/f - 7 Z� -- Lk- 3 �
S' atone Telephone
SECTION 3: DESCRIPTION OF PROPOSED % (ORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ er of Units_ Other ❑ Specify:
Brief Description of Proposed Work': e co G L
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building $ I. Building Permit Fee:$ Indicate how fee is determined:
�. 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: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ J 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date ti
Name of CSL-Bolder list CSL l'vpe(see below)
1'• Description
Address U Unrestricted(up to 35,000 Cu. Ft.
R Restricted 1&2 Family Dwelling
Signature M Nlasunry Only
RC Residential RoofingCoverin.
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
IIIC 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
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.
Sianature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I, -o L (. ,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. 10
Print Name
ISgnSgna ofO r . -Agent ate
ned under the sins and enal[ies of er 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 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 780 CMR Regulations I I O.R6 and 110.115, 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 halfibaths
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.UX.Nf
PUBLIC PROPERTY
DEPARTMENT
ci,uea�atr n�+.•,,..
.N"VM 13eorA2dMGTou ltfaaT f S�uri VAffAplt>ZT17l0tf'0
HOMEOWNER LICENSE EXEMPTION
Pies" hint
Date l I- I �-- 161 t/
Job Location )C c kl v� -C
Horse Owner Address 2 S 13
Home Owner Telephone
Ptesent Mailing Address
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 licensei provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Pawn(s) who owns a parcel of land on which he/she resides or intends to reside. on
which there is, or is intended to Is% a one or two family dwellin& 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
"lwmeowner"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 "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 and requirements and that he/she
will comply with said procedures and requiem
H0MEOWNERS SIGNATLRE
APPROVAL OF BUILDING SPECTOR
See other side for state code
CITY OF S.ULEA%vI, NLxss kcHusETrs
• BLiLDLNG DEPARTNEUNT
130 W.�sHLNGTON STREET, 3 'FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KiMBOILLEY DRISCOLL
INUYOR THOMAS ST.PIERRB
DIRECTOR OF Punic PROPERTY/BCII.DLNG CO\MMIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 1 l 1.5
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
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
Signature of permit applicant
elate
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