20 PIEDMONT ST - BUILDING INSPECTION is
the Commonwealth of Massachusetts
/ Board of Building Regulations and Standards CITY OF
y a;1 SALE\I
t,y, Massachusetts State Building Code, 780 CMR Revised.11or 2011
/ Ls•
Building Permit Application To Construct, Repair, Renovate Or Demolish a
I One-or Two-Furnf jv Du elliug
This Section For Of7ici se Onl
Building Permit Number: Date Applied:
Building 011icial(Print Name) Signature Date
SECTION 1: SITE INFORMATION
.I Propert Address: 1.2 Assessors Nlap& Parc Numbers
.� l�w-r c7;lnFi5r
I.I a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
"toning District Proposed Use Lot Area(sq It) Frontage(IL)
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,§5�) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood"Zone? Municipal❑ On site disposal system ❑
Public[I Private❑ Check if yes❑ P P T
SECTION2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
- A66- Iy UJ6?e- III A 0IT tO
Name(Print) City.State,ZIP
20� tic-��rrrB>� sTiet 93S�F1 1 2 -rm mowtc�>"r .tJinQ u.t/� 'o .
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work-: r�,E fTLLz, t S/ 6!g�t aRFCK pbr,'C r?( 9 /X(Z /
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and \laterials)
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
'_. Electrical S
❑Total Project Cost (Item 6)x multiplier
i. Plumbing S 2. Other Fees: S
4. \lechanical III\':\C'1 S List:
5. .Vechmlical (Pin S Total All Fees: S
Su xessionl
, / Check No. _Check Amount: C;uh :\mount:__.--
C/ 6. Toml Project Cost: S Q�e�-� ❑ Paid in Full ❑Outstanding Balance Due:
J-
SF.CTION 5: CONSTR[ICTION'SERVICF.S
5.1 Construction Supervisor License(CSL)
ILcpiraliun Date
Name of C'SL Ilulder
List CSL 1)pe(.ice below) _
No. :mJ Street Type Description
CI unrestricted(Buildin's ti to 35,000 cu. 11.)
City✓foml.State.ZIP - li Restricted 1&2 Fainill Dwellin
M NIasonr
RC Roofin C'uverin
WS Window and Sidin
SF Solid Fuel Burning Appliances
I Insulation
'I'cic
5.2 R hone Finail address D Demolition
egistered Ilome Improvement Contractor(HIC)
I IIC Company Name or I IIC Registrant Nome HIC'liegistmtiun Number Fxp"J"on Date
No.and Street
Email address
Ci /Town, State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 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:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penji',a
rjury that all of the information
contained in this application is true and accurate to the best of my knd understanding.
7
8� 2a
Print Otsner' ir:\uthori[eJ Agent's Name(lilcc[ronic Signature) ,11e
NOTES:
1. An Owner who obtains a building permit to do his/her own worner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Prol not have access to the arbitration
program or guaranty fund under NLG.L.c. I�12A.Other importation on the HIC Program can be found at
�t�� An:_as Information on the Construction Supervisorn be found at try\tb.n ra i5.go�41ps
_2. When substantial work is planned, provide the information below:
Total floor area(sq. ft) (including garage, finished basemenL'attics,decks or porch)
Gross living area(sq. tT.l Habitable room count
Number of tireplaces__-_,___- Number of bedrooms
Number of bathrooms ------------------
__._____ N'umbcrofhalE'bachs
Ty pc of healing sys(enl - - ---- — ----
-------.-------- _-- Number of decks porches_F)peofcoolinesestrnt --- -----------
_ _._.-__---- --_-- Enclosed __Open
------------ -
3. "'focal Project Square Footage'may be substituted for"total Project Cost" ------ --- -
CITY OF SMY-Ni
PUBLIC PROPERTY
DEPAIM, (ENT
w.v..ur o.dr.aL
Vwroa 130wAUGNGUMsnasr9SuzyVwMAO&SK ne1976
r&L 9WO-9s99•FAX 975-740.9W
HOMEOWNER LICLNSE EXEMMON
Plan" Prime
Date 45 /�
Job Lacadas 2,9 PleWMew f 57-Ce?--T
Home Owner Address u 114
Home Owner Telephone -17-0 s t9 I4 8 -z
Presene Mailing Address 2-n /bPfccOWT G; 5/QyL�u ,u�Q Dlg,�v
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 who,does not possess a licensed provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Person(s) wbo owns a parcel of land on which he/she reside or interds 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"shal! submit to the Building Official,on a form acceptable to the Building
Official, that he/she be responsible for all such work performed wader the Building
Famit
The undersigned"homeowner"assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations
The undersigned "homeowner"certifies that hdshe understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNAMME YL2-
APPROVAL OF BUILDING iNSP C OR
See other side for state code
CITY OF S'U-&NI, 1tiLASS. aiusET"I'S
8t;ttDLNG DEPARTtLNT
r 120 W."HLNGTON STREET, 3iO FLOOR
h!L (978) 745-9595
FAX(978) 740.9846
K1JIHERLEY DRMOLL
,MAYOR 7110 tAsST.P[ERRS
DIRECTOR OF Pl: uc PROPERTY/BLIIDLYG COMMISSIONER
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 q is issued with the condition that the debris resulting from
this work shall be disposed of in a property licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
/1/)fii���57Dc /��E�'T/r1r17
(name of hauler)
The debris will be disposed of in
_ (name of facility)
(address of facility)
signature of permit applicant
/ Sk
4 date
:.bnud•bR