17 PRESTON RD - BUILDING INSPECTION (2) , C,(� [
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The Commonwealth of Massachusetts hSPECVIONAL SE V{CC CITY OF
9 Board of Building Regulations and Standards LE NI
` A � hfassachust s State Building Code, 780 CbiR1b NAa -2 P S tafexl mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
This Section For Official Use Only
1 Building Permit Nu ere Date Applied:
f Building Official(Print Name). Signature Date
SECTION I.:SITE INFORNIATION
1.1 Property A dress: n 1.2 Assessors Mop& Parcel Number
I`1 PreSFOc, Wyss
I.1 a Is this an acce ted street?yes V11_ no M1fap Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) - Frontage(II) -
1.5 Building Setbacks(R) .
Front Yard - . .Side Yards Rear Yard
Required - Provided 'Required- Provided Required Provided
f1.6Water Supply:(M.G.Lc.A0,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone? Muniei O On site dis sot s stem ❑lic❑ Private❑ - — Check if es❑ disposal y
SECTION 2: PROPERTYONVNERSHiPt'
2.1 O ert of Record: ,(l,Zt) :5A LY-t M A 7.0
�1me(Print) City,State,ZIP .,
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK](check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Cl Alteration(s) ❑ Addition ❑
Demolition Cl Accessory Bldg.❑ 1 Number of Units_ I Other ❑ Specify:
Bricf Description of Proposed Work':
X SECTION 4:ESTIMATED CONSTRUCTION COSTS
Itcm Estimated Costs: Official Use Only
Labor and Materials - -
I. Building $ D� p I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S / D b ❑Total Project Cost'(Item 6)s multiplier x
3. Plumbing S D jj a P Qther Fees: S I
4.1%lcclmnical (I-IVAC) S List:
5. Mechanical (Fire S Total All Fees:S—
sut
Check No. Check Amount: Cash Amount:
6. Total Project Cast: 3 I Daa ❑paid in Full ❑Outstanding Balance Due:
PAN% > -AzD 3 L�
_ ,- /ACC.1 I 4z-s l
t, `"""'r' SECTION5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number E.epiralion Date
.a•"' iZ4k I��li
N:aie of CSL Holder List CSL'rype(see below)
Type " - Description .
No.:mJ Street -
U I Unrestricted BuilJin s u to 35,000 cu. Il.
R Restricted 1&2 Famil Dwellin
Cityrruwn,State,ZIP M I Masonry
RC 1 Rootin Coverinit
VS
1Vindow and Siding
SF Solid Fuel Burning Appliances
1 I Insulation
Tcle hone Email oddne$s D I Demolition
5.2 Registered tiome Improvement Contractor(HIC)
HIC Registration Number Expiration Date
1IIC Company Name or HIC Registrant Name
No.mid Street Email address
City/Town, State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.15Z.0 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 Isbuance of the building permit
Signed Affidavit Attached? Yes ..........0 No...........0
SECTION 7a.OWNER AUTHORIZATION TO BE CONIPLETED W HEN'
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print O%mer's Name(Electronic Signature) Date
SECTION 7b:OWNEFe OR AUTHORIZED AGENT DECLARATION
By entering my name below,)hereby attest under the pains and penalties of perjury that all of the information
in this applicatio true and accurate to the best of my knowledge and understanding.
cont7Pri •r's ur i uthormcd Agent's N um• IEI ct nic Signature)
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
_._.....__. __(not ireegistered in the Home Improvement Contractor(HIC)Program);will lid have access to the arbitration
program or guaranty fund under M.G.L.c. 141V Other important Information on the HICTrogrnm can be t'ot
w+vw mas+.aov'oca Information on the Construction Supervisor License can be.found at www•.nmss._ov.'dns
2. When substantial work is planned,provide the information below:
'total floor area(sq. R.) "s ,(including garage, finished basementlattics,decks or porch)
Gross living area(sq. R.) 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 t'or,,loud Project Cost"
a
QTY OF SALEM, MASSACHUSEM
BUILDINGDEPARTMENT120WASHINGTONSTREET,3" FLOOR
TEL. (978)745-9595
KIMBERLEYDRISCOLL FAX(978)740-9846
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLICPROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRI T.-
Date
Job Location_ ) V P 1 M V C
Home Owner Address 1 1
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 he/she will comply with such procedures
and requirements.
s
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR
OTYOFSALEA ALISSAC-3USETIS
Bui DDvc DEFAxnv-w
120 WASiS7REET,3=RLOOR
7kL(978)745-9595.
FAX(978)740.9846
BIIv�ERLEYDRiSQ'�LL
MAYOR ftu"STARM
DmEcroRoFPLzucrxcFmY/BmDnQc cownwomm
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 111.5 Debris,
and the provisions of MGL c40, S 54; Building Permit g is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
C".
(name of hauler)
The debris will be disposed of in:
(name of facility)
as At r-Y
(address of facility)
Signat re of ap I' t
Da e