13 PUTNAM ST - BUILDING INSPECTION 1
The Commonwealth of Massachusetts
UBoard of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, Vh edition OF SALEM
/ „ Revised Junma-Y
n Building Permit Application To Construct, Repair. Renovate Or Demolish a :/R).Y
1 1 One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Nu ber: Date Applied:
Signature:
Building Commissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Proper�t Address � 1.2 Assessors Map& Parcel Numbers
L�j r
1.to 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 11) Frontage(11)
1.5 Building Setbacks(R)
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: 1.9 Sewage Disposal System:
Zone: _ Outside Flood Zone?Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owners of Record:
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
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rt�srau -A4pg6a> m JX/
r -AT-- 20 - OQS
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building S 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical S ❑Total Project Cost(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
.,.., - \ Check No. Check Amount: Cash Amount:
6. Total Project Cost: S 4., 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
, � License Number Fapimtiun Date
Name of C'SI.- I lulder List C'SL Type(see below)
T Description
Ad s U unrestricted(up to 35,000 Cu. Ft.
xR I Restricted Ik2 Family Dwelling
Sign' V
M I Masonry Only
RC I Residential Roolinu Covering
rcicp me WS I Residential Window and Siding
n � SF Residential Solid Fuel Burning Appliance Installation
� 2 D 1Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152. 1 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 ..........O No...........O
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.
Siamoure of owner Date
SECTION 7b:OWNER'DR AUTHORIZED AGENT DECLARATION
1, as Owner or Authorized Agent hereby declare
that the atements and i n on the f re are going application a true and accurate,to the best of my knowledge and
behalf
Print Name
Signature of(honer or Authorized-Agent Date
(Signed under the pains and penalties of 'u
NOTES:
I. 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 W have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.R5• respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage• finished basement/attics.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
J. "Total Project Square Footage" maybe substituted for"Total Project Cost"
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In%uranca Company Name. 7,``C �' v
Policy ♦ur Self ino. Lie.A 7 61 Expiration Daw. /O -
Job Vfft Athkce:T_p2 Le 4.-'a � Ciry/3uWZipe � ? o
.%track a copy of the workers'coepeaales polky dahnfim pop(showing the pOW ousbte and eviel s dari}
Failure to mum covorsp u required undo action 25A of MOL a 132 can Isar to the impooidon oreriminal ponattia ofa
fins up to 51.300.00 snd/es onwyear imprisonmen%u wale as civil penalties in the forts are STOP WORIL ORDEO an/a floe
Of up to S:50.00 A Jay againss the violates. IN alviaod that a copy of this 3wstemom maybe rurwa rdad to the 011lce of
Incc.beatiutu ol'tha QIA far insurance covcmp wsillvasiaL --
/da honey /}t w/re tee rwd prw d e/p r/rq tAer fee inforwrdow prorihrl alero is rat rw :nude.
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I%tulav Authority (circle See):
I Ilu4td of Ilwltb 1. HudAing I)rp.rtmvnt 1. CitY/fowo Clok A. flecrrical IAxpector 9. Plumbing Impactor
6.01life
.,.stake Pcnaw: _ Pliant t:
CITY OF SALEM
PUBLIC PROPRERTY
" DEPARTMENT
NIr1 ''NIA '1I I 'C N'A,1eft..✓Ns1111 1•\II]I. \LNi11IIIdI •;I'/
\I . .•e 111:Y..4.j4'1VN �1'\!t:'1�a•i!.?'IeM
cAAS.quirci rwnll demolition DKlronova ion w i�
ork)
In accunlaltcc with the sixth edition of the State Building Code, 730 CMR section 111.3
Debris, and the previsions of MGL a 30,s issued
MGL e
is issued with the condition that the debris resulting floor
Building Permit Nam_ - 1 licerwd waste disposal fatality as defined by
phis work shall he disposal of in a proper Y
111. S 150A.
The debris will be trunsportcd by.
pA1ne ur haukrl
1'lia debris will be
disposed of in :
J
.iallaltue of p.rntil apptiaant
date