32 B PALMER ST - BUILDING INSPECTION Zs
C2 L{2-7 � I8 �
the Commonwealth of Massachuse At SER`1�CE CITY OF
WBoard of Building Regulations%iet��R► SALEM
Massachusetts State Building Code, 780�CMR�C, to Revised Shur 2011
ti Building Permit Application To Construct, RepairItAln %e rr Demolish a
�+ One-or Two-Fmnily Dwelling
This Section For Official Use Only
Building Permit Number: Date.Applied:
Building Otticiul(Print Name). Signature., - - ate
SECTION 1:SITE INFORMATION'
1.1�Prgpe ty Address: 1 ' u EProperty
p& Parcel Numbers
L I a Is this an 3cce ted strete0yes no Parcel Number
1.3 'Zoning Information: ensions:
Zoning District Proposed Use Frontage(It)
1.5 Building Setbacks(it)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water upply:(IvI.G.I.c.40,§54) 1.7 Flood Zone In formation: 1.8 Sewage DJaposat System:
Public Private❑ Zone: _ Outside Flood Zo Municipal On site disposal system ❑
Check if es
SECTION 2: PROPERTY OWNERSRIP4
2.1 OwnY t of Record:
o PoI p_
uen P � Aw
t�J�me(Print) City,State,ZI
nL 0-`f5t- 3'{{ ���4ennt�i ��Ve .eom
No.and Stre t Telephone Email Address
SECTION 3: DESCRIPTI N OF PROPOSED W RK. (check n that apply)
New Construction❑ Existing Building cal Owner-Occupied 011epairs(s) Alterotion(s) ❑ Addition ❑
Demolition ❑ . I Other ❑ Specify:
Brief Description of Proposed Work-: k eqef MY W a L \3
SECTION a:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials) -
I. Building S , o I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Costr(item 6)x multiplier x
3. Plumbing $ �%gther Fees: S
d.Mechanical (I-IVAC) S List:
5.Mechanical (Fire Total All Fees:S
Suppression)
Check No. Check Amount: Cash Amount:
6."rural Project Cost: S 5 0 a 9 9 ❑Paid in Full ❑Outstanding Balance Due:
J
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) .,,,
License Number E.epim[ion Dale
Name of CSL Holder
List CSL Type(see below)
Type Description
No. ;aid Suet e s
U Unrestricted((Buildings tie l0 35,000 cu. It.)
R Restricted 1&2 F:unil Dwellin
Cityrl-own,State,ZIP M Masonry
RC —lioo—fing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Espirution 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.§ 2500)),
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 7u:OWNER AUTHORIZATION:TO BE COMPLETED WHEN:
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matte relative to work authorized by this building permit application.
/ 2 1
Print Owner's Mmue( lectront afore) Dale
SECT t 7b: OWNEW ORAUTHORIZED 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 an ccur to the best of my knowledge and understanding.
Print Owner's or \uthonzed Agent's no(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 nut 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 m:us.eov'ocn Information on the Construction Supervisor License can be found at www.mnss.^ov'dys .
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.) ZC1 0 `• .(including garage, finished basement/attics,decks or porch)
Gross living area(sq. It.) _ Habitable room count
Number of fireplaces O Number of bedrooms ?
Number of bathrooms Number of half/baths
Type of heating system—9 Number of decks/porches �L
"rypeof cooling systcm w.QQ1 Enclosed Open_
3. "Total Project Square Footage"may be substilutcd fix rotal Project Cost"
CITY OF SALEM, MASSACHUSETTS
r s I BUILDING DEPARTMENT
120 WASHINGTON STREET,39°FLOOR
TEL. (978) 745-9595
FAx(978) 740-9846
KIMBERLEY DRISCOLL
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONRvIISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
�1
Date %_0 \71 4
Job Location w10
Home Owner Address 59,bAA, Q1 10
Present Mailing Address = — �Olmu oA a,.� '
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 that 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 "homeowner" assumes responsibility for compliance with the State Building Code and
other applicable by-laws and regulations.
r
The undersigned "homeowner" certifies that he/she understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such r�ocedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INS P CTOR