25 PARLEE ST - BUILDING INSPECTION (3) I
f� The Commonwealth of Massachusetts CITY OF
I� r Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CIVIR AL
71 Revised cLtnr 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dtivelling
this Section For Official Use Only
Building Permit Number.. Date plied'
4 %4/13.
Building Official(Print Name) :`Signature -. : Date
SECTION I: S[TE INFORM ION
LI Property Address: L2 Assessors Map & Parcel Numbers
.2 s Oaf IEB S,�c��
1.1 a 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(it)
Front Yard Side Yards Rear Yard
F1.6
quired Provided Required Provided Required Provided
ater Supply: (M.O.L a 40,§54) 1.7 Flood Zone Information: L8 Sewage Disposal System:
❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION2:, PROPERTY'OWNERSHIF�
2.1_�gqwnej t of Record:
Name(Print) City,State,ZIP /
�f �Ptn/cE S�T 97d'-75'/-7�9 ��✓J.�a, SSC0�3.C�i»�
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF. PROPOSED WORK''(cheek all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other fid Specify: O
Brief Description of Proposed Work':
.z iAl_
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: 11
Item Official Use Only,.,
Labor and Materials
I. Building S L Building Permit.Fee S Indicate how fee is determined:.
❑ Standard City/Town Application Fee'.
2. Electrical $ i
❑"focal Project Cost (Item.6)x multiplier x
7Plumbin.,oS 2. Other Fees: $AC) i List:lAllFees: SCheck No. Check Amount: Cash \nwunt/, fatal Project C ust S � ❑ Paid in Full 0 Outstanding
-- 6 l3,dmue Dui: — _
SEc'rION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL I lulder
List CSL Type(sae below)
No. and Street Type Description
U Unrestricted Buildin s u to 3i,000 cu. ft.
R Restricted 1&2 Family Dwelling
City/Town, State, ZIP M Nlasonr
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
[ Insulation
"rele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
I IIC Company Name or FI(C Registrtnu Name
No. and Street Email address
City/Town, State, ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. t52. § 25C(6))
Workers Compensation Insurance affidavit mast 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 AUTHORIZATIONTO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 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.
Print Owner's Name(Electronic Signature) Date
SECTI N 7h: OWNEW OR AUTHORIZED AGENT DECLARATION
By enterin i name be w, I hereby attest under the pains and penalties of perjury that all of the information
contai e i this appli lion is true and accurate to the best of my knowledge and understanding.
f u vn 's or Autl uric-ed:\gent's N:mic(Electronic Signature) D:ue
NOTES:
I. :\n 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 fluid under M.G.L. c. I42A. Other important information on the HIC Program can be found at
%aww.11cuS,1'ov/,x Information on the Construction Supervisor License can be found at www.ntass.gm llgt
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. It.) _ _ Habitable room count _
Number of fireplaces-,--- Number of bedrooms --
Number of bathrooms --- Number of halt'baths —_ -- --
I'vpe of henting system - -_-"-_-_ _----. Number of decks/porches _--
I'�peot Cooling sy;tcin Enclosed O en
i. Iaal I'roj��t Square Irn,uafe mn be �ub;tituted [:,r"I'„cal Ih ogectCo;t'
, . y
CITY OF S.ULE.bi
PUBLIC PROPERTY
DEPARTNENT
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HOMEOWNER LICLNSB EXE.m"j0j*(
P1ew /lrlit
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Home Owtser Address
Horns Owner Telephone
Present Mailing Address
The current exessrpdaa of"Homeowner"was extended to inchds owner-occupied
dweuin;s of me Units or tear ad to allow such homeowners to engov m individual for
hire who does not possess a Ileersu`provided that the owner acts as suparvisor.
D6FMMON OF HOhMOWNBA
Poron(s) who owns a pea A of land on which he/she resides or Intends to redden on
which them is, or is intended to be, a one or two unify dwelling, attached or detached
structure/ accessory to such use and/or rarm structures. A person who construct@ more
than one home in a two year period shall not be coneideaod a homeowner. Such
SW
"homeowner"s submit to the Building OQlci4 an a form uceptabld to the Building
Official, that he/she be responsible for all such wort performed under the Building
Permit
The undersipted "homeowner"assumes responsibility for compliance with the Stud
Building Code sad other applicable by6laws and regulations.
The undeniSned "homeownce certiftes that he/ a dentan the City of Salem
9uildin j Department minimum inspection edt _un and r uimments and that he/she
Mill comply with said procedures and re entL
HOMEOWNERS SIGYATLM
.VPROVAL OF SUILDIYG NSPECfOR
See ather side far state code