20 PARK ST - BUILDING INSPECTION 1'he Commonwealth of Massachusetts CITY OF
i
Board of Building Regulations and Standards"t SALEM
Massachusetts State Building Code, 780 CMR Rerierd.Ilur m/I
a.,
Building Permit Application To Construct, Repair. Renovate Or Demolish a
One-or Ttvo-Familp Dieelling
This Section For Offici Use Only
Building Permit Number: Da AAppplied: — _
/O7
Building Oltkial(Print Nmne) Signature Date
SECTION 1:SITE INFORMATION
roperty Address: 1.2 Assessors Map& Parcel Numbers
�a p6>2lz ST• SPEC r fl ,
1.la 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 It) 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.I-c.40.§54) 1.7 Flood Zone Information: I.—age Disposal System:
osa
Zone: _ Outside Flood Zone? Municipal ❑ On site disposals)s stem ❑
Public❑ Private❑ Check if ycs❑ P P >'
SECTION 2: PROPERTY OWNERSHIP'
2.1 nertof Recor :
N,mte(Print) City,State,!
Qt,,sq t
No.and Street 'relephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Esisting Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Nu er of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only 4
Item (Labor and Materials) S.
I. Building S I. Building Permit Fee: S Indicate how fee is determined:2.
❑Standard City/Town Application Fee 4�
Electrical S
❑Total Project Cost (Item 6)s multiplier s
t. Plumbing S 2. Other Fees: S
4. Mechanical Lli\':\C) S List: fas °
`;. .\lechanical (Fire --- .�
_ S Total All Fees: S
tiu �ressionl
Check No. Check Amount: --_Cash:\mount:
G. Total Project Cost: S - ' ❑ Paid in Full 0 Outstanding Balance Due:
" 7
SE("PION5: CONS'rR11CTIONSERVICES
5.1 Construction Supervisor License(CSL)
_.__ _ Lieense Number lizpiraion Dole
Name—,If('SI. I IulJer
List CSL rope(see helow)_
No. :utJ Strecl Type Description
D l Inrestricted(Buildings u' n)35, 000 Ca. It.)
Citylfuwn.Slate,ZII' R Restricted IX2 Pumil Dwtllin
M Mason
RC Roolin,('ovcrin
W'S Window and Sidin
SF Solid Fuel Buming Appliances
_ I Insulation
"role hone Entail address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or I IIC Registrant Nmue I IIC Registration Number Expiration Date
No.and Street
Email aJJrcss
Ci /Town, State,ZIP "felt hone
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
flasOwner of the subject property, hereby authorize on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Nante(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I 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.
16�6ZCE NAO�aa� O _
114(nsner s or ApthonecJ Agent s Name(Llectronic.Signn»ne) Dale
NOTES:
• I, An Owner who obtains a building permit to do hisiher 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
%)%L.aim— t;ok `ca Information on the Construction Supervisor License can be found at uww.mass.sot 111s
2 When substantial work is planned,provide the information below:
Total floor area(sq. R.) _(including garage, finished basement'attics,decks or porch)
Gross living area(sq. 11.) — Habitable room Count
Number of fireplaces--___-- Number of bedrooms -------
Numberofbathrooms — --------
-------------_._-_--- NumbcrofhalE'baths
1}pe of heating system --__-- _----- N — -- ------
umber of decks porches_
.. .f)pe of eooline s)stcnt -__ _ _
-__ --------
3. -rota) Project Square Footage-map be substituted fir"rol:d Project Cost.
t
CITY OF S.V &Nf, NLASSACHL'SETTS
RALOLYG DEPAIMONT
120 W-kSHNGTON 5TURT, }1O FLOOR
Tt+L (979) 745-9595
KIJ®ERLBY DIUSCOLL
F,4.x(978) 740-9846
MAYOR Ikoxu ST.Pmxn
DtAEGTOR OF PCBLIC PROPERTY/BCQDLVG CO-%alISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
rn accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL a 40, S 54;
Building permit M disp is issued with the condition that the debris resulting from
this work shall be osed of in a properly licensed waste disposal facility as defined by MGL c
I 11, S 150A.
The debris will be transported by:
n1�A2C�L Wa��q
(name of hauler)
The debris will be disposed of in :/
(name of facility)
(utdress or racillly)
elynalure of permit applicant
o . 1 fC/
Mite
e .
CITY OF SMXL NI
PUBLIC PROPERTY
DEPAR'T1dENT
KV o. �
wrn i>ovAou�w�asssn.sr 44,-- Vwosoasrrnoll'e
HOMEOWNER LICLNSE EXEMPTION
Pfeaw Prtet
Date l0 - I f - I I
Job Locadois ao PN�I' S k
HomeOenerAddress aSc� r 1F eel ST ta�rc�FrEcf>
Horne Owner Telephone 3�g -5 :,7 3 R 6
Present Mailing Address W AT(F2 S'c. la as T l€I n rns> n1 A g
The current exemption of Homeowners"was extended to include owner-occupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
hire who.does not possess a licenser provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Person(s) who owns s parcel of land on which he/she resides or intends to reside.on
which then 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 hdshe 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 requirements. /
HOMEOWNERS SIGNATL794 ZOO v
APPROVAL OF BUILDINGINSPECTOR
See other side for state code