32 PICKMAN ST - BUILDING INSPECTION The Commonwealth of Massachusetts CITY OF
I — - Board of Building Regulations and Standards
\Q I Massachusetts State Building Code, 780 CMR SALEM
g ReviseJ:Llnr?Ol!
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Fantily Dwelling
This Section For Offit b'nl Use Only .
Building Permit Number: Da Applied:r
Building 011icial(Print Name). Signature, Date
SECTION 1:SITE INFOWNIATION
1.1 Property`�Address: 1.2 Assessors Map& Parcel Numbers
32 �c1CMf�u
I.la 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 It) Frontage(It)
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:
'Lone: _ Outside Flood Zone?
Public❑ Private❑ Check ifyes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'"
2,,L.�Ownert of Record:
1<�2I<J-� '\�)"_N 1y 1S
me(Print) City,State,ZIP
3Z ofir 1�
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Workc:
e
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
. Plumbing $ Other Fees: S
4 ��I
. Mechanical (H List:
S List:
5. &kchanical (Fire S 'rot:d All Fees:S
Su ression)
Check No._Check Amount: Cash Amount:
6. Total Project Cost: S 3 ❑ paid in Full 0 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 13uildin s tip to 35,000 cu. It.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Nle hone Email address D Demolition
5.2 Registered dome 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.151§ 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...........❑
SECTION7a:OWNER AUTHORIZATION,TO BE COMPLETED WHEN.-
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING.PERMIT
I,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 OR AUTHORIZED AGENT DECI.ARATION-
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained 'n this a 'cation is true and accurate to the best of my knowledge and understanding.
Pr' ) ier's AM Mize Agent's Name(Electronic Signature) Date
NOTES:
f. 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. I42A.Other important information on the HIC Program can be found at
www.nms,.!Lovr'oca Information on the Construction Supervisor License can be found at www.mass.,ov.!d .
2. When substantial work is planned,provide the information below:
'rota) 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 healing system Number of decks/porches ,
'type of cooling system Enclosed Open
1. Total Project Square Footage"may be substituted for'Total Project Cost"
i
CITY OF SALE.NI, T%IASSACHLSETI'S
13LILDIING DEPARMENT
N+ 130 WAsHL:IGTON STREET, 3' FLOOR
TEL (978) 745-9595
F.Ax(978) 740-9846
KI.NiBERLEY DRISCOLL
ti4,�YOR THObtAS IE ST.PRAH
DIRECTOR OF PUBLIC PROPERTY/BUILDNG CO\LUISSIONER
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 111.5
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 of hauler)
'fhe debris will be disposed of in
(name of facility)
(address of facility)
A"
sign; re of permit applicant
c�i ,3 C> �3
late
'It'I)Ill'JIi.IK
CITY OF SALEM
PUBLIC PROPERTY
DEPAR-MLENT
a, nowt OAMLL .
w,a
i�e��11�i.�O1�r1aR•1W4.%AWA*krsrts 0I9V.
ru. •Y.kt,s'tr4764
HO&*"OWYER LICLNSX EXCUFFIGIN
P1eue Aiaf
Date 3 d �3
lob Loe.adon
Home Owner Addr ese
Home Ownw Telepboea ny t- Ir C Z-34 z
PteuM Mailing Address _32 T ccK",,N
ne current exemption of"HomeownereP was erterded to imill rowr occupieddwellings of two Units or fan and to AMW nwh htomeownen to engage an individual for
hire who does not posseae a ticaiee�provided that the Owner acts as supoviaor.
DEFINMON OF HOMEOWNER
Persson(s) *he owns a parcel otLrd on which hdshs resides or interrde to realdey on
which there Is, or is intended to bq a cue or two lkmily dwelling, attached or detached
structures accessory to.such use and/or rum$Mx twm A person who constructs more
than one horns in a two year period shelf not be considered a homeowner. Such
"homeowner"shall submit to the Building OQlcial,on s foam acceptable to the Building
O111cial. that hdshe be responsible for all such work performed under the Building
Permit.
Ths undenipwd "hameewnes"assumes responsibility far compliarsoe with the State
Building Code and other rpplieabie by4sws And reluladons.
l'.@ undmigned "homeowner certifies that hdshe undmtands the City of Sslerrt
Building Department minimum inspection procedures and requirements rnd that hdshe
will comply with said procedures and requirements.
H0 IE01ANERS SfG:lA rLR8 r
kPPROVAL OF 9U/L0IVG 4VSPECTOR
ice other side for state cads