4 PATTON RD - BUILDING INSPECTION (2) The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR
Reriserl:b/ur 2011
l
Building Permit Application To Construct, Repair, Renovate Or Demolish a
1\\ ^ One-or Two-Fcrrrrily Divelling
�Jl This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name) Signature
SECTION 1:SITE INFORMATION
I.kPrymn
ss�� (^` can Mn 1.2 Assessors Map & Parcel Numbers
I.I a Is this an accepted street?yes —U"n`o S v't'1 Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(It)
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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: ��,em m� �\Q—Ih
X Name(Print) City.Slate,ZIP )
\,&tom 9?a -): z2m ��ect>nn��R►a M5�-(AC(1
No.and Street Telephone Email
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s)X I Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
f'l
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical IFIVAC) $ ._ List:
5. Mechanical (Fire
Suppression) $ MQI Total All Fees: $
Check No. Check Amount: Cash Amount:
x' 6. Total Project Cost S 30 0 paid in Full ❑Outstanding Balance Due:
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL I(older
List CSL Type(see below)
No. ;md Street Type Description
Li Unrestrict 5,000
R Restricted Ik2 Fainily Dwelling
Pity/Down,State,%IP M Masonr
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
l'cic hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
f IIC Registration Number Expiration Date
I fIC Company Nmne or I IIC Itegistrant Name
Nu. attd 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
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
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 trueand accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent'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 fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
wwo% m:us-L�u�_oca Information on the Construction Supervisor License can be found at w it ka_nms_.avLl is
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. R.) Habitable room count _
Number of fireplaces _ Nwnber of bedrooms _
Number of bathrooms_ Number of half/baths _
Type of heating system _ Number of decks/porches
Type of cooling system Enclosed _Open
3. "total Project Square Footage"may be substituted for"total Project Cost"
1
CITY OF S'U.E.NI, NL-1SSACHUSETI'S
BUILDLNG DEPARTMENT
120 W.iSHLNGTON STRM. 3'FLOOR
` I'M (978) 745-9595
FAX(978) 740-9846
xta®ERLEY nRiscou
MAYOR THo.%w ST.P[Eans
DnRECTOa OP PLBLIC PROPERTY/at:MnLYG COMMISSIONER
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 l t 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit rk is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111,S 150A.
The debris will be transported by:
h�r-
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature ofpeimtt applicant
l atC
CITY OF S.0 Em
PUBLIC PROPERTY
DEPARnA, LENT
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HOMEOWNER LICLNSE EXE.MMON
Pleaas plat
DW
Job Location IZAs/ r�
Homo Ownw Add rese
Home Owoor Teiapboer
Psesmt Mauling Addsem Q
The current exemption of"Homeowners"was asttanded to include*wow-occupied
dwellinge of two Unib or lees and to allow such homeowners to eagage an individual for
hire who.does not possese a licass%provided that the*wow actr as supervise►.
DEFIPRITON OY HOMEOWNER
Person(s) wbe owns a parcel of land on wbicb hdsbe neides or Intends to reside.on
which then is, or is intended to be, a one or two limily dwellinS attached or detached
structures accessory to such use and/or firm sttuetune, A person who coaatnucts more
than one home in a two year period shall not be considered a homeowner. Such
"homeownd'shail submit to the Building Omcial,on a form acceptable to the Building
Official, that he/she be responsible for all such work performed under the Building
Permit
The widersigned"homeowner"aaaumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner'testifies 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 SiGNATLIU
APPROVAL OF WILDING P,iSPECTOR
See other side for state code