33 PICKMAN ST - BUILDING INSPECTION j6 ry -rgSz- $zs C-4P, s �1
'Che Commonwealth of Massachusetts REC EATY OF
Board of Building Regulations and StankN&AECTIONAL SER IC SALEM
qJl Massachusetts State Building Code, 780 CNIR p R i d,thir 1011
Building Permit Application To Construct, Repair, Renov
NIbfjrAsh'a �'
One-or Ttvo-Fmnily Dwelling
[� This Section For Official Use Only
4^�J Building Permit Number: Date Ap e�f��^_
Building Official(Print Name). Signature
SECTION 1:SITE INFORtNAT1O*
1.1 Property Address: 1.2 Assessors biap di Parcel Numbers
1 L I a Is this an:a ted street?yes ✓no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(it)
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? Municipal❑ On site disposal system ❑
Public❑ Private❑ — Check if es❑
SECTION2: PROPERTY OWNERSHIP,'
2.1 Ownern of Record:
time(Print) City,State,ZIP
No.and Street Telephone Email Address
SECT16N 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction O 1 FE., isting Building Owner-Occupied arl Repairs(s) ❑ 1 Altemtion(s) Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work:
SECTION a:ESTIMATED CONSTRUCTION COSTS
Item Estimated Cool: Official Use Only
Labur mind Materials)
I. Building S . I. Building Permit Fi e:S Indicate how fee is determined:
❑Standard Cily/Town Application Fee
2. Electrical S - ❑Total Project Costa(hem 6)x multiplier x
3. Plumbing S 2 Other
Fees: S
d.Xlechanical (FIVAC) S List:
5.Mechanical (Fire S Total All Fees:S
Suppression)
Check No. Check Amount: Cash rUnount:
6. Total Project Cost: S ' ❑paid in Full ❑Outstanding Balance Due:
5EEDr 0va (,Z� Z
) SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
—I&9—�'.—_ License Number Expiration Date
None of CSL Holder '• List CSL Type(see below)
Type Description
No. and Street
U Unrestricted UuilJin s u to 35,000 cu. It.)
R Restricted 112 Family Dwelling
C ityrrown,State,ZIP bl Masonry
RC Rooting Coverin
WS 1Vindow and Siding
SF Solid Fuel Droning Appliances
I Insulation
'rcle hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expirution Date
HIC Conipcmy Name or IIfC 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 PEPNIIT
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relati to work authorized by this building permit application.
i �4-1
Pri Owner's Name(Electronic Signature) Dole
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.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do Iris/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program),will Lint 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 cov:'ocn Information on the Construction Supervisor License can be found at www.mass.eov'Jas _
2. When substantial work is planned,provide the information below:
Total door area(sq. ft.) .(including garage, finished basement/attics,decks or porch)
Gross living area(sq. R.) Habitable room court
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
'rype of heating system Number of decks/porches
Type orcoolingsystem Enclosed Open
3. "Total Project Square Footage" may be substituted for"rotal Project Cost"
CITY OF SALEM, MASSAC HUSETTS
BUILDING DEPARTMENT
• I 120 WASFENGTON STREET, 3µD FLOOR
�R TEL. (978) 745-9595
FAX(978) 740-9846
KINMERLEY DRISCOLL
MAYOR THOMAs STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date
Job Location 33 .✓ s �
Home Owner Address- 5AI� x
Present Mailing Address -54+..�II�
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
g P Y P
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.
/ If EOWNER'SSIGNATURE
( APPROVAL OF BUILDING INSPECTOR