1 PERSHING RD - BUILDING INSPECTION (2) �25^ G� S�-1 �R-�:G%( y Z '18 9$�
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� � , The Commonwealth ofMassachusetts
� °y� ` Board of Building Regulations and Stan ��Ep CITP OF
I� Massachusetts State Building Code,57E���"p,� SERv��ES SALEM
p�� p Revised Mar 2011
Building Permit Application To Construct,Re ,Renovate Or Demo '
One-or Two-Family Dwellin q A ��3
This Seetion F'or Official n '
� Building Parmit Number: Date Ap ied:
� — '�'�' W✓ b�� �
y -Bwldmg Offcial(Prmt Namej � � �� � Sigaaflae . . . D e ...
J SECIYON 1:SITE I3VFORMATION
I 1.1 Pro erty Address: 13 Assessors Map&Parcel Numbers
� � 1 ��;,ko �
11a Is this an acce ted stree[?yes_ no Map Number Parcel Number
�
1 1.3 Zoning Information: 1.4 Proper[y Dimensions:
!,
j� j Zoning DisVict Proposed Use Lot Area(sq ft) Frontage(ft)
l.�
r 1.5 Building Setbacks(ft)
��
� Front Yard Side Yazds eaz Yaz
� Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Iuformation: 1.8 Sewage Disposal System:
I Public� Priva[e❑ Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑
Check if yesO
SECTION 2: PROPERTY OWNERSffiP' n
2.1 Owner'of Record:
� U.1 e�.y a7' �c��e.v.��S �a Oy�� M�- C�1`�7-�t
Nazne(Print) City,State,ZTP k
f `�j rciT'� ����� N1�M�3s1�4�m)S�C[MQril�.
No.and Street � Telephone Emai]Address
SECTION 3:DESCRIPTION OF PROPO5ED WORK'(check all that applg)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work2:
� 1�,,,11c1��a (�l �,, rn al.ocac -f S}e(JS
1h /2 o20d7 CaAE ,, �/9r�S
SECTION 4t ESTINLITED CONSTRUCTIQN COSTS
Item Estimated Costr.
Labor and Materials ����al Use Only
1.Building $ OQ� oo 1• BuildingParmitFce;$ Inc3icatehowfeeisdetermined:
2.Electrical $ ❑Standazd City/Town Applicario�t Fee .
❑Tokal Project Cost3(Item 6)x multipiier
3.Plumbing $ ?. Other Fees: $ /����
4.Mechanical (HVAC) $ List ��� �-.� �•1
5.Mechanical (Fire $
Su ression Total All Fees:$
Check No. Che.ck Amount: Cash Amount:
� � 6.Total Project Cost: $ � �oo ❑paid in Full O Outstanding Baiance Dne:
M I� I ��.—r� S� 28
SECTION 5: CONSTRUCTfON SERVICES I
51 Construction Supervisor License(CSL) ", � �
� License Number Expiration Date �
Name of CSL Holder I
List CSL Type(see below) I
No.and Street • �Type . ��Description
U Utu�estricted uildin s u to 35,000 cu.ft. '
R Restrictedl&2Farni1 Dwellin
City/I'own,State,ZIP M Maso .
RC Roofin Coverin
WS Window and Sidin
SF Solid Fuel Bw�ning Appliances �
� I Insulation
Tele hone Email address D Demoli[ion �
5.2 Registered Home Improvement Contractar(HIC)
HIC Registration Number Enpiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
Ci /I'own, State,ZIP Tele hone
SECTIOlY 6:WORKERS'CO1kIPENSATION INSURANCE AFFIDAVIT(ll•I.G.L.c.152.§ 25C(�)
Workers Compensation Insurance�davit 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 AUTHORIZAI'IOIY TO$E COMPLEI'ED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BULI.DING PERJVIIT
_ _ _ .
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. I�,
Print Owner's Name(Electronic SignaNre) Date
SECTION 7b:OWNER�OR AUTHORIZED AGENT DECLARATION
By entering my name below,I here v attest under the pains and penalties of perjury that all of the information
con ' ed in this a. ic ion tr e an ccurate to the best of my knowledge and understanding.
� a ' ` 9' ZO s
Prm[ wner's Authorized g nYs ame(ElecVonic Signalw�e) a[e
N(?TES:
1. 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 ConVactor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important infortnation on the HIC Program can be found at
�nnv.mass. ovQ loc�Information on the ConsVuc[ion Supervisor License can be found at www.mass.eov/d�s
2. When substantial work is planned,provide the information below:
Total floor azea(sq.ft.) (including garage,finished basemenUattics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of batluooms Number of halflbaths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Squaze Footage"may be substituted for"Total Project CosY'
Q QTY OF SALEM, MASSACMEM
%�,
BUILDING DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
\?nw TEL. (978) 745-9595
FAX (978) 740-9846
KIMBERLEY DRISCOLL
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date
Job Locatio
Home Owner Add
Present Mailing Ad
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 (IA" c 0'
APPROVAL OF BUILDING INSPECTOR
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