4 PLEASANT ST - BUILDING INSPECTION The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY SALEM
Massachusetts State Building Code, 780 CNIR Mar
Q� NN Revisedd Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or S Tevo Family Dtivelling
'this
ction For Official Use Only
Building Permit Number: Date A�plied y '
Building Official(Print Name) Signature, - Date
SECTION 1: SITE INFORTNIATION
ZI'3
operty Address: 1.2 Assessors Map & Parcel Numbers
this an accepted street?yes_ no Map Number Parcel Number
oning Information: 1.4 Property Dimensions:
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.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public ❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION!:; PROPERTY'OWNERSHIP�*
2.1 Ownert of Record:
GcWIS ol27o
Name(Print) City,State,ZIP
q PG45f{54 rh- ST. (g78)oi9g,-2_O7o
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF,PROPOSED WOW'(check all that apply)
New Construction ❑ Existing Buildingx Owner-Occupied Repairs(s) Alteration(s) �. Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
$f1 TNPDo" R6_1V0V.4-T!0AJ CPL,4C,11l 6-- Flx i URE-1
�/ A7�1 v SlNK /nJ 5"An I� 4_E7G,4�r/0A..1S 4S f leESe_1V;-�
SECTION 4: ESTIMATED CONSTRUCTION COSTS-,.
Estimated Costs:
[tern Official Use Only?., -
Labor and Materials
I. Building s 1. Building.Permit Fee. S Indicate how fee is determined-.
2. Electrical s ❑ Standard City/'foivn•Application Fee.
- ❑Total-Project Cos t',(Item. )xmultiplier x
3. Plumbing S 2. Other Fees: s
1. Mechanical (HVAC) S List:
5. Mechanical (Fire $
Sn> cession) Total All Fees: S
Check No. Clieck AmOnnt: Cash Amount:.
6 'Total Project Cost: S to AO o ❑ paid in Full ❑ Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL I lolder
List CSL'Pype(see below)
No. and Street Type Description
U Unrestricted Buildin s up to 35,000 cu. ft.
_ R Restricted 1&2 Family Dwellin
City/Town, State, ZIP NI Masonry
RC Roofing Covering
_ WS Window and Siding
' SF Solid Fuel Burning Appliances
I Insulation
"I'cle hone Email address D Demolition
5.2 Registered Home Improvement Contractor(111C)
IIIC Registration Number Expiration Date
HIC Company Name or FIIC 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 PERMIT
1, 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 penalties of perjury that all of th8"information
contained in this application is true and accurate to the best of try knowledge and understanding.
�l�If�i2p L 3 - 13 - i3
Pfln(OlVatrS Jf AnfllJrl Ltd:agent's Nnnte(Elccn'onic Signature) Date
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 liome Improvement Contractor(HIC) Program), will not 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
trww.mass.''ov oca Information on the Construction Supervisor License can be found at www.mams.ggL' I
2, When substantial work is planned, provide the information below:
Total floor area(sq. ft) _(including garage, finished basement/atticS, decks or porch)
Gross living area(Sy. ft.) Habitable room count
Number of fireplaces Number of bedrooms --_--
Numbu of bathrooms Number of haltibaths _
type of heating.syslrnt _-_---- - - Number of decks/ porches --
I'ypeofcooling System------"—_--_. Enclosed Open
..i. `'Fotal Ptojcct 5yuarc Footage' may be substituF.:d (or.:h)MI Project CoA, -__-- ---
CITY OF S.UENM) -I,-1SSACHUSETTS
' BuL=G DEPARTMEINT
120 %V.ASHINGTON STREET, 3'FLOOR
TEL (978) 745-9595
KI\IBERL.EY DRISCOLL F.VX(978) 740-9846
AWOR THOMU ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BCILDNG COSOASSIONER
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 l 11.5
Debris, and the provisions of tb1GL c 40, S 54;
Building Permit ik is issued with the condition that the debris resulting from
this work shall be disposcd of in a properly licensed waste disposal facility as defined by MGL c
I11, S 150A.
The debris will be transported by;
ovE C
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of tacility)
signamm of permit applicant
3 - 13- 13
date
id" ,��r.ex
CITY OF smx. Nlr
PUBLIC PROPERTY
DEPARTMENT
V\1YYfr N.r' Y�
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HOMEOWNER LICLNS6 EXE.MFrioV
Pfew Mat
Date 3 - /3 - 13
Job Locatlos `A PLt,q s q V i S7-
Home Owner Addreas -1-- f�c c srs a+vT s r wr
Home Owner Telephone 4 s? 9 4 0 3 0
Preaed M=Hag Address 44Pc E A 4 4/l�T S T Ci4L EM
The current exemption of"Homeowstare was exteladed to include owner-occupied
dwouings of film Units or leas and to allow ruck homeowners to engsgs an individual for
hire who.does not possess a license provided that the owner acts as supervisor.
DERNMON OF HOMPOWNEA
Person(s) *he owns s pared of land on which hdshe resides or intends to redde6 an
which there i6 or is intended to be,a oae_or two firmly 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 Ofllcial,on a form acceptabb to the Building
Official, that he/she be responsible for all such wont 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"certiAes that he/she undentands the City of Salem
Swlding Department minimum inspection procedures and requirements and that he/she
Will comply with said procedures and requirement&
HOMEOWNERS S[GVATLM
.APPROVAL OF BUILDING ViSPECTOR H
See other side for state code