2 PARLEE ST - BUILDING INSPECTION (2) fhe Commonwealth of Massachusetts (N PE� I$�®� SE VICE5
� Board of Building Regulations and Standards SALEM
OYI Massachusetts State Building Code, 780 CMR .Pe Mj(p/,lar�h� . 48
Building Permit Application To Construct, Repair, Renovate Or Demolish a IY �w�
One-or Two-Family Dwelling
This Section For Official Use Only '
Building Permit Number. Date Applied
11hi � .
DuilJing Otticial(Print N:une). Signature- Date
SECTION 1:SITE INFORMATION'
1. roperty Addr ss: E1.2Eft�
Parcel Numbers
,, rV ,- fee S�"re�fi
I.la is this an accepted street9 yes no Parcel Number
I.3 Zoning Information: sions:
'Coning District Proposed Use Frontage(It)
pl.6Water
lding Setbacks(R)
Front Yard - Side Yards Rear Yard
Required Provided Required Provided Required Provided
Supply:(M.QL c.40.§5d) L7 Flood Zone Information: Lg Sewage Disposal System:
Zone: _ Outside Flood ZoneTMunici al ❑ On site dis sal s stem Private❑ Check if es❑ P disposal y
SECTION2: PROPERTY OWNERSHIP!`
2.1 Ownert of Record: t/�r. S� )�� m�
�(J � r j City.State,IZIP rYFGC' 1 U e r—
\ ohm (Print) Y77��-14-="
oL 6�a 1'- I eC Sf-r eft R7LZV- 373 C 14 m
No.and Street Telephone ��( ry Email ddress
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) ❑ 1 Altemtion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Descriution of Proposed Work':_"
t
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 7ject
Official Use Only
Labor and Materials
I. Building S mit Fee:S Indicate how fee is determined:
ty/Town Application Fee
2. Electrical S Cost"(item 6)x multiplier x
3. Plumbing S Sq.Mechanical (HVAC) S
5.Mechanical (Fire Total Ali Fees:S
Suppression)
Check No. Check Amount: Cash Amount:
6. Total Project Cost: .5 ❑Paid in Full ❑Outstanding Balance Due:
ci� ��(z�) (,i Lc- P("
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number E.cpiration Dale
Nano of CSL Holder List CSL'rype(see below)
Type - - - Description
Nu. and Street
U Unrestricted Duildin s u to 35,000 cu. It.
R Restricted I&2 Fam11 Dwellin
Cityrrown,State,ZIP M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I I Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Dane
HIC Company Name or HIC Registrant Name
No. and Street Email address
City/Town, State ZIP TA 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 Wtiance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No...........❑
SECTION 7a:OWNER AUTHORIZATIONTO BE COMPLETED WHEN. "
OWNER'S AGENT OR CONTRACTOR APPLIES FOR/,BUILDING PERMIT l _
1,as Owner of the subject property,hereby authorize �/ 2 0fe� Q�LSD l 0, � e -
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print 01
er's Na ne(Electronic Signature) DI e
w
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.
Pri t Owner's or Authorized Agent's N;un• Elecronic Sigt are) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who(tires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program), will/tilt have access to the arbitration
program or guaranty fund under 1M.G.L.c. 142A.Other important information on the HIC Program can be found at
�eww mass eov'oea Information on the Construction Supervisor License can be found at ww'w�as -
2. When substantial work is planned, provide the information below:
"total fluor area(sq. RJ .(including garage, finished basement/attics,decks or porch) j
Gross living area(sq. 11J Habitable room court
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
'rype of heisting system Number of decks/porches
Type of cooling system Enclosed Open_
J. `Total Project Square Footage" may bc,ubstituted tier"Total Project Cost"
T
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CITY OF SALEM, MASSACHUSETTS
BUILDING DEPARTMENT
5, 120 WASHNGTON STREET,3"D FLOOR
`3 s
\ � TEL. (978) 745-9595
FAX(978) 740-9846
KINIBERLEY DRISCOLL
MAYOR TrIOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONIlbIISSIONER
HOMEOWNER LICENSE,EXEMPTION
PLEASE PRINT
Date
Job location
Home Owner Address o� 1/Y�
Present Mailing Address oZ �ri ✓��e �t�e� S4/e,-r? l /�
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.
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 procedures
and requirements.
HOMEOWNER'S SIGNATURE �q^.ccr1__(/��C��
APPROVAL OF BUILDING INSPECTOR l
i1} QTY OF SALEM, MASSACHUSEM
K ft 7trj BUILDING DEPARTMENT
fw✓' " 120 WASHINGTONSTREET,3ADFLooR
' TEL (978)745-9595
KIMBERLEYDRISCOLL FAX(978) 740-9846
MAYOR THomAs ST.PIERRE
DIRECTOR OF PUBLICPROPERTY/BUILDING 00NmsSI0NER
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 111.5 Debris,
and the provisions of MGL c40, 5 54; Building Permit # is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, 5 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
/l/�-cfl2 S t y
(name of facility)
(address of facility)
o
Signature of applicant
Date