20 PARLEE ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
�- Board of Building RCgulalions and Standards I'c>It
Y Massachusetts State Building Code. 7SU C NIR, 7 edition
A)
Building Permit Application To Construct, Repair, Renocatr Or Demolish a KrrisrJ.!<urmit,
One- or Tnn-Family Duelling
h This Sec For Official Use Only
Building Permit N mber: Date Applied: o _
Signature:
ui i Commissioner/ In cc or it ildings Date
SECTION I: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map & Parcel Numbers —
l.la Is this an accepted
Mo Number ParcCI Numher street? nu P
1.3 Zoning Information: Li Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage (it)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
i
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 rystem ❑
SECTION 2: PROPERTY OWNERSHIP'
O we f tdn o
nPn
Name
(Print) Address 0 Service: /
U�) / 2
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied Repairs(si Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Bnef Desciip:ion of Propused Work': A �
C IC 2C ._LZ_ L 105�X C SC_ 17 lq"f
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OlTicial Use Only
(Labor and Materials)
I. Building $ C)C). fQ 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost (Item 6) .x multiplier x
i
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash :\mount:_-_
b, 'Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:__-___
SECTION 5: CONSTRUCTION SERVICES
5,1 Licensed Construction Supervisor(CSL)
License Number E\poation Date
_-
Name of CSI_- I]older
List CSL Type]see helow)
\dAddress 'f e Descri pion
L Unrestricted(up l0 7i,000 Cu. Ft,)
R Restricted 1&'_ F,unilh Ds�elhrig
Signature .bl `•lasonry Onlv
RC Residential Roo:mL C."..-
Telephone \VS Residential \Vmdom and Siding
SF Rcsideuual Solid Fuel Buono_ \ p plume InsLillamm
D Residential Demohuon
5.2 Registered Home Improvement Contractor (HIC)
HIC Company Name or fIIC Registrant Name Registration Numher
I 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.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, ,j 0 nn C �L L:_U , as Owner or Authorized Agent hereby declare
that the statements and information on tore furegoing application are true and accurate, to the best of my knowledge and
behalf.
JUYLn n c- rY1 --
Print Name / / 10 (�
Sig knodtc"rth,pains
Oer or Authorized Agent Date / V L�
ISi and penalties of eriu )
NOTES:
I. An Owner who obtains a building permit to do his/her own work or an owner who hires an unregistered contractor
(nut 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 and
Construction Supervisor Licensing (CSL)can be found in 780 C'MR Regulations I IO.R6 and I IO.RS. 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 h:alt76aihs
'type of heating system _ Number of decks/ porches _
Type of cooling syslen) Enclosed _ Open
3. "Total Project Square Footage- may be substituted for "Toad Project Cost"
CITY OF &UY. i
PUBLIC PROPERTY
DEPARTMENT
iu NmW.01"n.K.".v
NAYM --. .-i 3o WAmmc.mN ST Em#SALejw.M&fA0/L'sErrs 01970
-- - - TEL 9711-73S-9S9S 0 FAY:9711740.964
HOMEOWNER LICENSE EXEMPTION
Please Print —
Date S I I -2
Job Location
Home Owner Address
Home Owns Telephone - a-
Present 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 license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER r
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 b
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 hetshe be responsible for all such work performed under the Building
Permit.
The undcrsigned "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 SIGNATURE iJ
APPROVAL OF BUILI)ING CY CTOR
See other side for state code
CITY OF SALEM
' ,i ' " ' PUBLIC PROPRERTY
.
DEPARTMENT
,,I n I \C'.\,nc:,,:ON i-1 T ♦ S.ti rat. \L It ,r i
'I'I 9'8-'4i-9;'); ♦ 1:.NN: 9'874 9846
Construction Debris Disposal Affidavit
(required fur all dcnwlition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CN1R section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit ff _. is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
1 11, S 150A.
The debris will be transported by:
(name of hauler)
I he debris will be disposed of in
(name of facility)
(address of Iacility)
i
---.- _. .signatw'c 1't perillit
.— date ---