29 PUTNAM ST - BUILDING INSPECTION The Commonwealth of Massachusetts Town of
►, Board of Building Regulations and Standards
1 � Massachusetts State Building Code, 780 CMR, 71h edition Buil mg Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Tivo-Fan it Dwelling
This Section For Official Use Only
EBuildEingPeEnnitNum er: Date Appiied:
Signature: $'�'''I lei
Building ommissioner/Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 p Qert�Ld�s: r— 1.2 Assessors Map& Parcel Numbers
Q "I �t 4p!�n✓i
Ma Number Parcel Number
1.1 a Is this an accepted street'7 yesJ� no_ p
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(it)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.(j.L c.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal [3 On site disposal system ❑
Public❑ Private❑ Check if ZesCl
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Reco O� �u,f� m �'t y �'Fl j e?•yt
AIPtRed � JuMAS Q
Name(Print) Address for Service:
X a Z ff - 7v5 -7l �y
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK` (check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Aiteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. O, Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building E I. Building Permit Fee: E Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Costs(Item 6)x multiplier x
3. Plumbing E 2. Other Fees: E
4. Mechanical (BVAC) S List:
5. Mechanical (Fire 5 Total All Fees: E
Suppression)
Check No. _Check Amount: Cash Amount:
X6. Total Project Cost: OG, �(, 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
N.4mc of CSL-Hylder
List CSL Type(sec below)
Address T Descri tion
U Unrestricted i(up to 35,000 Cu. Ft.)
Signature R I Restricted 1&2 Family Dwelling
M 1 Masonry Only
RC Residential Roofing Coverin
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 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 .......... ❑ 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.
Signature of Owner Date
ECTIO WNERt OR AUTHORIZED AGENT DECLARATION
1• ,as Owner or Authorized Agent hereby declare
that the stat ents an on the foregoing application are true and accurate,to the best of my knowledge and
behal ��Jy)G�
Print
Signature Owner or Authorized Agent Date
Si ned der the pains and penalties of perjury
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 not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I 10.116 and I I O.RS, 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
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
K
Vwroa 130 wAvuranoN 9MEffr•SuEK NAStAQIl56r73 01970
TEL 97S-70-9S"# FA%.976-740.994
HOMEOWNER LICENSE EXEMPTION
Pits"Print
Date G' 21.o `l
Job Location
Home Owner Address S/xwl E
Home Owner Telephone k
Present Mailing Address S F
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 who 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 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 requirements.
HOMEOWNERS SIGNATURE /
APPROVAL OF BUILDING LNSPE R
See other side for state code
y
CITY OF SALEM
a PUBLIC PROPRERTY
DEPARTMENT
..,,I ,. ,I: �', 0. "III•. .. '�:>:�I I r � 1.�1I �I. \L�"u .. ,. I . ,:I'' _
Construction Debris Disposal affidavit
(rciluired li,r all demolition and rcnovation work)
In accordance wth the sixth edition of the Slate Building Code, 780 C'MR section 11 1.5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit h is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal lacility as defined by MGL c
l 11. S 150A.
The debris will lie transported by:
Qll-K� Lkth YlR.4
� v (name tit hauler)
I lie debris will be disposed ofiin,:
(name of acility) r
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