13 PICKMAN RD - BUILDING INSPECTION (2) ir�'- i4 z5- Il��
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
q Nassachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied: -7 I{
Building Official(Print Name) , igna Date`
SECTION 1:SITE INFORMATION
1.1 Propert \ddress: � 1.2 Assessors Map& Parcel Numbers
13 fClU11llA poa
I.I a Is this an accepted street?yes no Map Number Parcel Number
L3 Zoning Information: L4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq fq Frontage(II)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
/ Zone: Outside Flood Zone?
Public(Y Private❑ — Check ifyes❑ Municipal 13 On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1n Owner'of Record:
/iN/72£tn!y 111auzaA)-TAtisaa.m .5ct6ut /Pia . 0/F76
Name(Print) City,State,ZIP
/3 Prcaina,✓ Rd, 978-71/5-474J4
No.and Street lblephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. Number of Units Other ❑ Specify:
Brief
Description of Proposed \ ork2:__ i
SECTION 4: ESTiMATED CONSTRUCTION COSTS
[tern Estimated Costs: Official Use Only
Labor and Materials)
I. Building $ J?5 6-0 I. Building Permit Fee: $ Indicate how tee is determined:
2. Electrical $ ❑ Standard City/Ibwn Application Fee
❑Total Project Cost,(Item 6)x multiplier _x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (I IVAC) $ /� List:
5. Mechanical (Fire $ —
Suppression) Total All Fees: $
11 Check No.__Check Amount: Cash Amount:
6. Total Project Cost: S 3 5 Cl paid in Full ❑Outstanding Balance Due:__
Ct
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date f
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 l&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(111C)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Strecl Email address
Cit /rown,State,ZIP Telechone
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: OWtNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
conk ed in this application is ue and accurate to the best of my knowledge and understanding.
14 -
Print(Avncr's ur Authoriz J Agent's ame(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
www.nmss.eov/oca Information on the Construction Supervisor License can be found at www.ntass.gov/dIi
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.) I labitable 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'
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QTY OF SALEM, MASSAC HUSETTS
BUILDING DEPARTMENT
i� frr 120 WASHNGTON STREET 3" FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KINIBERLEY DRISODU
MAYOR TrIOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date 7 / /z \
` Job Location 3 1"t C-(L/Vtc>i
Home Owner Address /3 [/ lCV1'J4Al ��• SaC£'"q j Ma .'
Present Mailing Address 13 P/CKM4nj /`¢• $�`�4i1 �nnc
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
APPROVAL OF BUILDING INSPECTOR