38 PHILLIPS ST - BUILDING INSPECTION t
The Commonwealth of Massachusetts
!� CITY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official U Only
Building Permit Number: Date Ap ied:
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Num ers
38 Phdi,'p z S iC, zleoZ-
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(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 yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
Swt� I4-ta6e ►� J� 16L+
Name(Print) City,State,ZIP
38 PGt '/IiDS St 97g 741'ZS38
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building,* Owner-Occupied,J Repairs(s)/9 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': e- w 'ro �0 0.n
St —(-Ca Avt
e 4 G t lk ho-p&woj JP �^t l
GC, o a r lc c lnas,c6oark
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 5 000 r 0 p 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ /o op,DO ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ / 0 o D,oU 2. Other Fees: $ '
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire Suppression)
$ Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 7 O00' 00 ❑ Paid in Full ❑ Outstanding Balance Due:
L
t
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu. ft.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC 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 application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW 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.
Jw f i1
Print Owner's or Authorized Agent'• ame(E 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
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.inass.gov/dps
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 area(sq.ft.) Habitable room count
Number of fireplaces Number 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"
CITY OF S.k1YDvI
PUBLIC PROPERTY
DEPAIM,(ENT
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Nwvaa 130 WADUFACMM SMEW•S LAK%1ASACWSffT17 ot1'0
T1L 978.745.95"•EAa./78.7169W
HOMEOWNER LIMNSE EXEMMON
Plesw lrrlet
Data
Job Location 5 Ps Ph , 1(j
Home Owner Address
Home Owner Telephone 2 7 s=s 74-/ Z 5-3 8
Present Mailing Address s�P -c_ '
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units Of leas 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 OP HOMEOWNER
Pawn(s) who owns a paeeal 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
structured 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
'?tomeowner'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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
grill comply with said procedures and requirements.
H014EOWY RE
ERS SIGNATU
APPROVAL OF BUILDING INSPECTOR
See other side for state code
„
CITY OF S.Ut &Ni, NL1SSACHUSETTS
B1;u�LNG DEP.1RTNONT
110 WA NLYGTON ST1M )'O FLOOR
TIEL (978) 745-9595
FAX(978) 740.984
KIMBERLEY ORMOLL
,MAYOR Tliomu ftftIIrtt;
Drawroit OP made PIIOPERTY/HCILEING C0.%W1SSrONER
Construction Debris Disposal Aft7davit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section I l 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit M 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 NIGL c
l 11. S 150A.
The debriis�will betra(nspo/rtcd by:(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facilay)
siynatu permit applicant
—� date
:,M1nvd•6ti .