68 PIERPONT ST - BUILDING INSPECTION (4) Y
�l The Cummonwealth of Massachusetts
!J Town of
Board of Building Regulations and Standards
y Massachusetts State Building Code, 780 CMR. T°edition Building Dept
t �
Building Permit Application To Construct, Repair. Renovate Or Demolish a tti'W"die&
One- or Tteo-Fowi(t Dwelling
This Section For Official Use Onl
Building Permit Number. Date Applied:
Signature:
Budding Co sioner/ n Buildings Date
ECTION 1:SITE INFORMATION
1.1 Property Addr ss: 1.2 Assessors Map& Parcel Numbers
In R L`rpo� S
Ma Number Parcel Number
1.Is Is this an accepted street?yes_ no p
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(B)
1.5 Building Setbacks(ft)
Side Yards Rear Yard
Front Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.i.c.40,154) 1.7 Flood Zone Information: t.g Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public Private ❑ Check if vesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record: eta � Alf 4. f L �T , 0 P76 0
Ja . t Tti � s
Name(Print) Address for Service: —t
g 5�2
Sign ur Telephone
SECTION l: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building Owner•Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Ooly
Item Labor and Materials
I. Building f I. Building Permit Fee: f Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical f ❑Total Project Cost'(Item 6)x multiplier x
J. Plumbing S 2. Other Fees: f
4. Mechanical (NVAC) S List:
1 Mechanical (Fire S Total All Fees: f
Suppression)
Check No. _Check Amount: Cash Amount:_
6. Total Project Cost. S �3 D ❑ Paid in Full ❑Outstanding Balance Due:
d S i c,
i
f �
SECTION S: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
bceme Number E.apuation D e
N;)me ol'CSL. ljpider
List CSL Type(,cc below)
Address T' Desc t non
U Unrestricted u to 35. Cu. Ft.)
Sill
R Rcstrncted Ik2 Famtl welLn
N Mason Onl
RC Rcvdcmml Roofi Coverin
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration N tuber
Address
Eapirati Date
Signature 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 .......... O 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.
Si nature of Owner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of peru
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 have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. FL) (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 halfbaths
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
PUBLIC PROPERTY
DEPARTMENT
�,.a�arsv om
VAVM I M WASUNGUM Sneer•3AIR+t VAUACHLSam 0110
ter.rs-74 -osss • f..:93.7+0•964
HOMEOWNER LICENSE EXEMPTION
Please Ihl�t _ ._
Date
Job Location Sow f S�
Home Owner Address
Home Owner Telephone
Prom Mailing Address
The current exemption of"Homeowners"was extended to include owneroccupied
dwellings of two Units or less and to allow such homeowners to engage an individual for
hire who.does not possess a license,provided that the owner acts as supervisor.
DEFINIITON 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 other applicable by-laws and regulations.
The undersigned "homeowner"certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
UR HOMEOWNERS SIGNATE /�
APPROVAL OF BUILDING INSPECTOR
Sce other side for state code
CITY OF SALEM
PUBLIC: PROPRERTY
' DEPARTMENT
',I I_, \1 � 'c'a. ".1..nlf • \\11 \I, \t 1••U .I-� .
III 9'y 1: 1: : � l �\ Y .V V, ' ♦L.
Cotistruction Debris Disposal Aflid.n it
octimied Iihr all demolition and rvnu%allon 1vulk)
In accurdance 111th the sixth edition of the State Building Code, 780 CAIR section III 5
Debris, and the provisions of AIGL c 40. S 54:
Building Permit to Is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal Ibcility as defined by MGL c
I1I. S 150A.
The debris will be transported by:
I lumc of hauler)
I he debris will be disposed of in :
(nalnr of I,.JcI Ily)
1.ulJrc.. ull]a dllvl-
laulwe d ptln�/ .yglha Jnl
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