7 PIONEER CIR - BUILDING INSPECTION $3 q Z�ro
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code,780 CMR RECEIVED Revised
Building Permit Application To Construct,Repair,Renova1W&ffeM0fiej3hla Sf RVICES
One-or Two-Family Dwelling
This Section For Official Use Only X,q;4 3, -
Building Permit Number Date Applied: . .....L,
,
glonhirp. D Ln Building OTcia[(Print Name) S1
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SECTION 1: SITE INFORMATION
1, 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1.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 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.G1 c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private 13 Zone: Outside Flood Zone? Municipal 0 On site disposal system 11
Check if yes[]
q, SECTION 2:'PROPERTY OWNERSHW
2.1/IgRvnerof 0-,cord:
rn 7501h It I lest MA ot97o
Nan—ie(Print) I City,State,ZIP
7 P-ovieer Crelc 979_q30_,g1l3 e5e,'vll plve I OD 11. (QAj
III No.and Street Telephone email Addrfe—ssl
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) , :4,
New Construction 13 Existing Building 0 Owner-Occupied�ARepairs(s)X I Alteration(s) 13 Addition n-
Demolition o Accessory Bldg. U Number of Units_L I Other 13 Specify:
Brief Desen'ptiozof Prposed Wov: &�Nbt� ythke-ft 4!tA
"it
U
SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: . ......
Item Official Use Only,,-:'_
(Labor and Materials)
1.Building $ I.-Building Permit Fee: Indicate how fee is determined:
2.Electrical $ 0 Standard City/Town Application Fee.--......
❑Total Project Copse(Item-6)x multiplier
3. Plumbing $ i Other Feii'. `5
4.Mechanical (HVAC) $ Llst:, 4
is
1,0
Y
5.Mechanical (Fire
TotalAll Fees: $�1,1'1'11`11,��N_�!��:�,
Su ression)
Check o. Chick Aniount:' Cash Amount:
0' Balance 6.Total Project Cos $ 00 '0 Paid in Full 0 utstanding Balan' Due:- "
CzSLs1-4T To it. 0
?1 14
SECTION5: CONSTRUCTION SERVICES
1 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(Build in s 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 Bunting Appliances
I Insulation
Tele hone 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 Telephone
SECTION 6 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M G L c''µ152.§ 25C(6)) x
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuuance 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.
Ave
Print 0 er's Name(Ele tronic Signature) Date
SECTION 7bi'OWNEW,OR AUTHORIZED AGENT DECLARATION
By entenirignyf ame below,I hereby attest under the pains and penalties of perjury that all of the information
contai d ' Gs applicati s r accurate to the best of my knowledge and understanding.
Print er's or Authorized Agent's Name(Electronic Signature) Date
m 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. a 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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 SALEM, MASSACHLTSETTS
, m
BUILDING DEPARTbIENT
120WASHINGTON STREET,30.OFLOOR
\a TEL.(978)745-9595
FAX(978)740-9846
KINMERLEY DRISCOLL
MAYOR TrIOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date lq_9— E n \
Job Location -7 f ibn se - 6�i (2 Sae kf�t A*�- 01270
Home Owner Address S R k4-LP
Present Mailing Address
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
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 h I comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR