23 PICKMAN ST - BUILDING INSPECTION e The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SdMar
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date A lie :
Z
Building Official(Print Name) Signatu Date
SECTION 1: SITE INFORMATION
1.1 Prop t Address: 1.2 Assessors Map kParcel Numbers
I.In Is this an accepted street?yes / no Map Number Parcel Number
1.3 Zono 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:
Zone: _ Outside Flood Zone?
Public Private❑ Check if yes❑ Municipal 0—On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2. Owner of�BR7te.fford: '
C/�i.fOn s C'Ltl9l�NO. �RY✓IN51yh OJlat,(/N A4,' d,970
Name(Print) City,State,ZIP
z1, IICbkztpi cif' 771s• 9g8 9t/IZ 14SoA. �lArrr..f}t�El9ttt4t�
No.and Street Telephone �— "�.mai A ti 4@
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other tf-Specify:
Brief Description of Proposed Work 2:
/J f 0! —A.Y/,3174 Wood MW
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost;(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $ h�
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
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 Tele hone
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: OWNER'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.
Print d'wner's or authorized genes Name(Electronic Signature) Date
NOTES:
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 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. ov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
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 SALE.NI
PUBLIC PROPERTY
DEPARTMENT
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Home Owner Ad*vA
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Present Mailing Address
net current exemption of"Homeowners"was extended to include owner-sceuplerd
dwellings ottwo Units or less mid to allow such homeowners to angsgs m individual for
hits who,does not possess a 114= r provided that the owner acts as supervisor.
DP.SINITION Of HOMEOWNER
Person(s) who owns a pence/of I=W on which Wafts resides or iatende to reside. on
which there is, or is intended to be.a one or two family dwoUing, attached or detached,
structures accessory to such use and/or tarns 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 Oi7ki4 on a form acceptable to the Buiidin;
Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned"homaowner"assumes responsibility for compliance with the State
BuPdirg Code and othma applicable by-law. and regWadory
The undersigned "homeowner"certifies that he/she understands the City of Salem
Suildin` Department minimum inspection urea and requirements and that he/she
will comply with said procedures and r i
HOMEOWNERS SIGNATLRS
APPROVAL OF &WILD X�SPECT6
See other side for state code
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