32 PICKMAN RD - BUILDING INSPECTION (2) �f0,
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The Commonwealth of Massachusetts F
O
Board of Building Regulations and Standards CITY
ITY
Massachusetts State Building Code, 780 CMR RevisedSALE r 20!/
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling
This"Section For Official Use Only
Building Permit N er. I baie:Applied:l2 2 13
Building f ictal(Print Nam . Sign[. Date
SECTION 1:'SITE INFORMATION'
1.1 Propert Address: 1.2 Assessors Map&Parcel Numbers
L l a Is this an accepted street?yes h 110 Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(R)
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:
PubliclM Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
12.l, Ownert of Record: 1� * ,
�G4Rr� ��znt�LS "'V O lcn O
me(Print) \ City,State,ZIP �
32 L hMGn �� -7%1-8 rr J3,- S \�y�l`GOtZS c� �R�oO• Cow
No.mid Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Constructions Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief D\scriptigp`Pof['roposed Work': p E6.o.5vc� sc..
��-ocu- rt 0 Co.a�tnMS-
SECTION'4:ESTIMATED CONSTRUCTION COSTS'
Item
Estimated Costs:Labor and Materials Official Use Only
1. Building $ O O 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 S 2. Other Fees: $
4. Mechmrical (FIVAC) $ List.
5. Nfechanical (Fire $ Total All Fees:S
Suppression)
Check No. Check Amount:. Cash Amount
6. "Pn[al Project Cost: $ I ( O D 0 Paid in Full 11 Outstanding Balance Due:
� 3
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL holder
List CSL'fype(see below)
No. and Street Type Description' .
U Unrestricted Buildings tip to 35,000 cu. ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Rooting 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
IIIC 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 PERNIIT
1, as Owner of the subject property,hereby authorize
t9 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 ORAUTHORIZED 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 true and 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 1M.G.L.c. I42A. Other important information on the HIC Program can be found at
www.mass.eo¢'oca Information on the Construction Supervisor License can be found at wwcvw.mass.aov/dm
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"
COMM
CITY OF SM-EM
PUBLIC PROPERTY
DEPARTMENT
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HOMEOWNER LICLNSL EXE.tilPTIOV
Plea" "I
Date $
Job Locsdon
Home Owner Address
Home Ownsr Telephone _ ')K t — t S 3 — N-
hes"MailingAddress 32 c S2sEs� c6�C]
no curreat exesaptloo of"Homeowners"was extended to include ownsr-occupied
dw"Inys of two Unite or leas and to allow Bach homeowners to engage= individual for
hire wilts does sot possess a llem8e4 provided that the owner acts a supervia w.
DEFINMON OF HOMEOWNER
Person(s) *be owes a pared of land on which Wshs reaidp or intends to reside, on
which tiers it; or is intended to boo a one or two iltmily dweWngd attaehod or detached
stsxMM accessory to such use and/or rum sMscturea A person who constructs more
than one home is a two year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building OQfci4 on a form acceptable to the Building
OtPld 4 that helshe be responsible for all such wort performed under the Building
Permit.
The undersigned "homeowner"assumes responsibility for compliance with the State
Building Code and other applicable by-laws and reguladona
Tlss uadersigrsed "homeowner"cerdAes that hdshe understands the City of Salem
Bwldin f Department minimum inspection procedures and requirements and that hdshs
.vill comply with said procedures and requirements.
HOMEOWNERS SIG;lA TUBE
kPPROVAL OF BU/LDIYG iNSPECTOR
See other side for stale colt
b" CITY OF SALEM, lLksSACHUSETTS
• 13ULOLNG DEPARTMENT
N 120 W.ASHLNGTON STREET, TO FLOOR
TEL (978) 745-9595
FA.Y(978) 740-9846
KIIjBERLEY DRISCOLL
MAYOR THOAtAS SY.PLERRfi
DIRECTOR OF PUBLIC PROPERTY/BlUMIDNG CON12MISSIONER
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 It 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# 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:
—� (name o' iauler
The debris will be disposed of in
Z'D
(name of facility)
(
(address of facility)
1 - nature of permit applicant
3 d to
JLI)1'IiJItIH: