2 PARLEE ST - BUILDING INSPECTION (3) t� The Commonwealth of Nlassachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR Sd Mar
Revised Mar 2011
W
Building Perms Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Parmit Nwnbert Date Applied.:;
�BuildingOfficial(PrintName) Signature Date.
SECTION 1:SITE INFORNLATION
1. roper%k d-rl ss* S L� 1.2 Assessors Map& Parcel Numbers
),
1.1a 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 ft) Frontage(ft)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yesO
SECTION 2; PROPERTY OWNERSHIP,
2. nnertofRecord:
a i� 1 "`i✓el" G/S� J iim � Y1�
Nam wen
Ciry,St e;ZIP ^�
I��t.,--Jew Sr�eGf' Ys37_7 />74r,'e4.racJye��`�, .l. c�ryl.
No.and Street - Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WOR V(check all that apply)
New Construction ❑ Existing Building ❑ 1 OwnersOccupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ umber of Units_ Other ❑ Specify:
B ' Description of Pr posed Work': 1 C
S
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only,.,
Labor and Lklaterials
1. Building $ 1 Building Permit Fee $ Indicate how fee is determined:
❑ Standard City/'town Application Fee
❑"C
2. Electrical $ 7
Total Pi•tiject Cost (Item.6)x multiplier x
3. Plumbing S 2. Other Fees: S
I Mechanical (HVAC) S List:
i. Mechanical (Fire $
Suppression) Total All Fees: 5
Check No. __Check Amount: _Cash Amount:
e, l'utal Project Cost: I ❑ Paid in Full Cl Outstanding B:dance Duo:
SECTION 5: CONSTRUCTION SERVICES
5.1 Cottsttvction Supervisor License(CSL)
License Number Expirition Date
Name of CSL I!older
List CSL Type(see below)
No. and Street Type Description
U Unrestricted(Buildings up to 35,000 cu. tt.)
R Restricted 1&2 Fijni[y Dwelling
City/Town,State,ZIP M Masonr
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
I'cle hone Email address D Demolition
5.2 Registered Home Improvement Contractor(111C)
HIC Registration Number Expiration Date
I IIC 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. § 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 applicatio
' � `-/
Print Owner' Nxmt(Electronic Sig,t fore) Date
a
SECTION 7b: OWNER' 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.
Print Owner's or r\udwrized:\gent's Name(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 not have access to the arbitration
program or guaranty find under NLG.L. c. 142A. Other important information on the HIC Program can be found at
w oca Information on the Construction Supervisor License can be found at www.mass,,jt v_'dL
2. When substantial work is planned,provide. the information below:
Total floor area(Sq. ft.) _(including garage, finished basement/attics,decks or porch)
Gross living:irca(sq. ft.) Habitable room count
Number of fireplaces_- -- Number of bedrooms _----.--__—_--
Number of bathrowas Number of halt'baths _
I'ypc oFheating System - --. ---_ __-- Number of decks/porches
----
Topeof'cooliegsystcnt__--------____---- Enclosed_-- __-- -_Open ----
l. "I'otAl Pn"jcct Syunro F(Jot:wc- utay be iub,tltutekl C i l'ol:il Project Cost"
vr CITY OF SiU EM jNL1SSACHUSETTS
7 t E3L:MD4\tG DEPaRnl.&NT
130 WASHNGTON STREET, 3w FLOOR
TEL (978) 745-9595
1Q.NWERIEY DRISCOLL F.tx(978) 740-9346
�At
%YOI THc.% SST.PLERRB
DIRECTOR OF PCBLIC PROPERTY/BUM.DD;G CONMI5SIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Coda, 730 CMR section 1 l 1.5
Debris, and the provisions of tb1GL c 40, S 54;
Building Permit h, is issued with the condition that the debris resulting from
this work shall be disposed of in a property licensed waste disposal facility as defined by MGL e
111, S 150A.
The debris will be transported by:
(name of hauler)
Tile debris will be disposed of in
-- - -
(name offacility)
(addres.v oflael ity)
s 'nature of permit a licant
3 ) ( 1_3
date --� -
CITY OF S.UE.Nf
PUBLIC PROPERTY
DEPARTPMENT
Vwroa l b w%owaGWW Sraaar•]A AK A%sAcm=m 6t9V
71L 1'0,745-91 ! •FAX VW46164
HOMEOWNER LICENSS EXE.r MOV
Ptew Mat
Dam Jul 13
Job Location
Home Owner Addrool e
Home Owner Telepboaa 7 C- 5
Preamt MailingAddress S�mP_
The current exemption of"Homeownars"was extended to include owner-occupied
dwellings of two Units or lea and to allow such homeowners to engage an individual for
hire who.dam not possess a liconso provided that the owner acts as supervisor.
DERNMON 0!HOMEOWNER
Persons) who owns a pared offend ost which he/she resides or intends to reside.an
which them is, or is intended to be, a one or two rawly dwelling, attached or detached
structutes accessory to such use and/or farm structureu A person who constructs more
than one home in a two year period shad not be considered a homeowner. Such
"homeownee sW submit to the Building Oilleial,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
vvill comply with said procedures and requirements.
HONEOwYERS S(GNATL-M :5aLva z
APPROVAL OF BUILDING NSPE R.� -
See other side for stawc