15 PLEASANT ST - BUILDING INSPECTION The ss Commonwealth of,,Muxhusrtts
m Hoard'of Building Regulations and Standards I OR
R 11]assuchusetts State Buitdmg Code 780 CMR T°edition MUNit IP 11 117
UJ6
But.
ldmg Permit Application To td'nstruct`Repair Renov.ue OrDetriolisfi Rci l,±u/Jaenuu
One-.or;T3to Fnnirty D)tethn` ; U 'tHhY
his Section Forgffi ' Usc. nl
6u¢Idtng'PermitNumber DA` Ii,,
'Signature:
r BmtdingCumintssiuncr7lnspeclaruFBmugs ds
. SECTION-l-SITE'INF RM4TION
1c1 Propertya ddresse- i.2 AssessoisMap&Parcel Numbers s
I PIu_[s,(his anuccepied-street t yes•' no MaP Nam6cr >. Penal Numh�r„„_„
2 3 Zomn g lnformalion L4 Property Qttrtetufons
v
' Zoning District �Propased Use„ Lai Anu(sq ti): Froniugg tit}
1:$ 8aiiding',Setbacl (ft) ,
. -Front §ide'VLrd9 - :RearYnrd
Rcyolred - Prondad Required Provided ' Regmred PmvWrd
fl.6 Water Supply tM,O L a d0,§54j 1.7 Flood Zone Infortnadon:,a 1.S Sewage Disposal System
Zane - Outside Flood 2oi¢e7
Pubis - -Pnvato❑ — Muniuput Omsnadisposal system Q
Check if ye sO .-''`.
$ECTION2: PROPERTY OWNERSI UPt'3
2.1 Owner¢of Record ' -
,�i�.Csfin
Ngme Pnat} Address for Service ,
St re TelI fi-
,SECTION 3 ,DESCRIPTION OF PROPOSED WORKz{etteck ollzthat agply)�E , , ,',
thew Constnichoq❑ `EK¢shdg-Bailding d ,O., }vner Occupied Alteraauq(s) ❑ ,,�Addrnon 0
De'moinion "? ❑ Y N Accessary Bldg O,y. umber of Units� "Other spcc�fy
Brief Description of Proposed ork3:-' "`
,y
SECTION 4:ESTIMATED CONSTRUCTION COSTS
,Estimated Casts
I¢ens - Oftictal.Use Qnly',x
{Loliorai d Materials)`
t-Buildin r $ I Building Permit Fee $ indicate tiow fee isiietermined:
g
Electnrnt $ w, ❑Stoddard Cityltown Application Fee
0 Total Project Cosft{Item 6)x multiplier x
3 Plumbing :, $ ' � Other Fees $ ` r
`- d ;Mechamcnl;;(HVAC), $ Gst / ,r
S.,Mechanical "(Fire. $
Su sion) Total All Fees $ ' ? i
Chc k No; Check Amnunt Cash Amount
6;Tote{ProUeet Cost ` ;$ ; O Paid'in FOU ` ❑Outstanding Balance Due.-
z
. a
.. .?3 k;; � � �.,, . SECTIONS„ COf!ISTRUCTCONSERYYCES .,. t i ,,,,,.ram
5 I Licensed ConstrucUbn Supervisor,(CSL) s
T
"' 5 LaenseNumbcr Ezpiniuun Da{�
Name ufCSL Holder -
a Cast CSL Type(ser helow) � ,
4ddnss ''
T ; xpescn uan
+ ' .0 "Unrestriet'iKlm
Fumil -Dwd6n
SilZnuture' M / Mnsa -"iC)nl
RC iutRiurin .cov'Fnn ° ti•x, '.
Te]ephone, ,;. = "� WS �= Rcsidentiu V✓indniv art&Sidra
lt6idealial.4uhd Fuel'Bumm 4 liana Urotaltaaun
' c - ,D.'.,; ..RusidcntiaLDrmnlidon:>, ,
5 2 RegCstered Home Eaiproveomnt Contractor(HICj
HIC Company Name or HIC Registrant Name;, : . egislration_Number
Address- -_ , .- _
'. Expimnon,bate
"Signature; Telephone s'-3
SECTION 6:WORKERS'COMPFNSATYON IAISURA(YCE AFFIOAYIT(M.GR c I52.$ 25C(6))
Workeni.ompt:nsaygn Insurnnce affidavit must be completed and submitted with this applicuaan 'Failure to pnivide:.
w 'this affidavit writ result to the`dental of the Issuance of_the buliding'permu
Signed Affidnvit'Attached? Yes ❑ ' No f3
SECTION 7a OWNER AUTHORIZATION TO-,BE_COMPLE7'ED WHEN
OWNER'SAGEN7OR'C R
' .
ONTRACTO APPLIES"FOA BUiI DING PERMIT.
Owner of the subject property hereby
-_ -au e` _ ` `• to act on my 6eha(f m all,matiers
relattvo �wor! aurhonze by[his bmlding IN ❑ppbcaaoa
F'
e
���,..,� -
5ECTION 71e: OWNERt OR AUTHt)RIZED AGENT.'DECLARA:TION
' I 'iis Owner ar Authonzed Agent hereby declare
tfia statements and information on the foregoing application are five and accurate;,ro thebest of my knowledge dad
behalf
Pnntl D�L� e L"Si satin weer or A th nzed A eat ;Onto
(Signed underihe dins"and" nalilte aF r u )
wNOTES
1 An Owner who dii[ains a bu;Idmg permit to do his/her own work;or do awnen who hires an unregistered cuntructnr
(not registered in the-Home Improvemeoi Contractor(HIC)Pingtum),will have aci ess to the urbitrat On,
In or gunrurity fund underM g L.c. 142A Other important information on the HIC Program ipd
Coasvction Supervisor Licensing(CSL)scan be found m 780 GStiiR Regu)ations 110 Rb:pnd i IO.R5 re�pet.tive]y
2 'When7subsmnnal3wbrk is planned provide_the information below:
Tula) floors urea(Sq.Ft) ` IncludIag garage finished buseinenNatnes decks ur purthl
Gross hJin`g urea'(Sq.;pt) , .Habitable root;;�rotmt- ; -
'M1Neimberiif.fireptaies - =Number`uf.tiedrooms
l_Numberot�tiattirooma" NumberofhiilUbat[u
'Type of tieahng systemNumlxr'of decks!parches` -
: Type of coo]mg system Enclosed = -Open
x
'3 'Total'"pro
. Square Fcotage'.'inriy 6e'substituted fa[""Total Projeet Cost
`:s
Uti� II
C
y
IN p
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STmJ�-
'L.G
CITY OF SMY. M
PUBLIC PROPERTY
DEPARTMENT
Vwvo� 130wtive►K.M3t9ssr03^WK 1KM01970
71n.97L7+S4S"• Fnx.975-74&994
HOMEOWNER LICENSE EXEMPTION
Pies" "t
Date T✓�� /7�
Job Location
Home Owner Address S
Home Owner Telephone
Present Mailing Address SX —,�-'
The current exemption of"Homeowners"was extended to include owner-0ccupied
dwellings of two Units or less and to allow such homeowners to engage an individual for
hire who.does not posse"a license,Provided that the owner acts as supervisor.
DEFINMON 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 dwellin& 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 r it ents.
HOMEOWNERS SIGNATURE
i
APPROVAL OF BUILDING INSPECTOR '
See other side for state code 1