3 PRESTON RD - BUILDING INSPECTION (3) r, The Commonwealth of Massachusetts Wieanw CITY OF
t Board of Building Regulations and Standards U' ' '
Massachusetts State Building Code, 780 CMR r�qq SALEM
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Building Permit Application To Construct,Repair,Renov �O 2 olish a
(r One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 P Addrf ss: 1.2 Assessors Map&Parcel Numbers
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1.1 a 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.G.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 2: PROPERTY OWNERSHIP'
2.1 Owner'of Re og rd:
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Name(Print) City,State,ZIP
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No.and Street - Telephone Ema Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building d I Owner-Occupied Gf Repairs(s) Ef I Alteration(s) ❑ Addition ❑
Demolition m' Accessory Bldg. ❑ I Number of Units Other ❑ Specify:
Brief Description of Proposed Work : C:.
{. P vs
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 1 h 0 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List: (�
5.Mechanical (Fire $
Suppression) Total All Fees:$
/ Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ / �� ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
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(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofin Coverin
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone 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. 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
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 penalties of perjury that all of the information
contained in is a lication is true d accurate to the best of my knowledge and understanding.
I Z /Z 711 6
x Print Owner's or Authorized Agent's lame(Electronic 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 Home 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
Information on the Construction Supervisor License can be found at
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"maybe substituted for"Total Project Cost"
CITY OF SALEM, MASSACHUSETTS
BUILDING DEPARTMENT
120 WASHNGTON STREET,31D FLOOR
TEL. (978)745-9595
KIMBERLEY DRISCOLL FAX(978)740-9846
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:/
DATE: IZ / Z 7
JOB LOCATION ov, Ze\
HOME OWNER ADDRESS:
PRESENT MAILING ADDRESS:
The current exemption of"Homeowners"was extended to include owner-occupied dwellings of two(2)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 own 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 the 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 he/she will
comply with such procedures and requirements.
HOMEOWNER'SSIGNATURE_(::� \
APPROVAL OF BUILDING INSPECTOR
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MAYOR Dj3wSTjM=
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Construction Debris Disposa/Affjdv t
(required forall demolition andrenovation work]
In accordance with the sixth edition of Nre Stabs Bufi fgB Code, M CA4k Secdan 11LS Debris,
and the PvvWM of MGL a10,S S4; BUMft permit# is Issuedwklh the
condition that the debris resuMW from this work shell be disposed of in a property licensed
waste deposit facility as defined by AOGL c lit S isK*
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of fadllty)
(address of facility)
Signature of ap licant
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Date