11 PYBURN AVE - BUILDING INSPECTION (3) Zlo.,elf
(L CITY OF
The Commonwealth of Massachusetts
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One or Two Family Dwelling
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SECTION SIT NF TION
1.1 s:A&)6 1;,Pfissors Map& Parcel Numbers
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Lla Is this an accepted street?yes_ no Map Number Parcel Number
13 oning Information: 1.4 Propertygmensions:
t_j I ZA?�*tA
Zonis g District Proposed Use Lot Area(sq ft) Frontagb(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 0 Zone: Outside Flood Zone? Municipal El On site disposal system ❑
Check if yesE]
'SECTION 2` PROPERT
2.1 Owner' fR o d-
%WIF ' ' , CCU
Name(Print) City,State,ZIP
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Naj - _qe6v I (WI,
No. and StredW Telephone Email Address (j
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3-,DESCRIPT r
New Constructionl] Existing Building 0 Owner-Occupied W Repairs(s) Alterations)cL�] Addition ❑
Demolition 0 1 Accessory Bldg. 11 Number of Units k_ Other 13 Specify:
Brief Description of Proposed Worker z
01P
SECTIONES 4 ESTIMATED.CONSTRUCTION COSTS�
Estimated Costs:
Official-Use Only Item
(Labor and Materials)
If Bdildffig,Perrii Permit Fee I ffidicAte-ho-w fee is determined: .
I. Building $
S fand'a tr L Qi,t
2. Electrical n,
13�TotaF,Pr, st",(Item 6)-x multiplier
C6
Fees 3. Plumbing 2.' Other , _
L Is
4. Mechanical (HVAQ $
5. Mechanical (Fire
Suppcession) TotalAII'Feml
Cheek, Check Amount, Cash Amount
6. Total Project Cost: Outstanding Balance ffue:
SE 11 CTION 5i 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 Mason
ry
RC Roofing Covering
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: 152.1§ 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'
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: OWNER! OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
ntar - �tt-ttris lication is true and accurate to the best of my knowledge and understanding.
C C, l2
r t Own is or Authorized Agent's Name(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
www.triass.gov/oca on the Construction Supervisor License can be found at www.mass.�gov.dos
2. When substantial work is planned, provide the information below:
Total floor 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 S.U.E*vf
PUBLIC PROPERTY
DEPARTNIENT
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HOMEOWNER LICE.�ISE EXE.tiIPTION
Pkase Frfra
pate 1/ l/ /
Job Loeatioo l� Y •� v
Home Owner Address ✓4 i..
Home Owoar Telephone
Nesmt Mailing Address �Irri ti�
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or fees and to allow such homeowners to engage an individual for
hire who does not possess a Hcar9s6 provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Peaonr(s) who owns a parcel of land on which hdshe resides or into ds to reside, on
which there is, or is intended to be,a one or two family dwelling, attached or detached
strtrctures accessory to such use and/or farm structure. 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 fort acceptable to the Building
Official. that he/she be responsible for all such work performed trader the Building
Permit
The undersigned "homeowner"assumes responsibility for compliance with the State
Building Code and other applicable by-laws and reguladons.
The undersigned "homeowner"certifies that hdshe understands the City of Salem
Building Department minimtun i tion procedttra and requirements and that hdshe
Will comply with said procedures an requirements.
HOMEOWNERS SIGNAM
.APPROVAL OF BUILDING NSP OR
See other side for state code
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CITY OF SALE.M. NSSACHUSETrS
BLWII GDEPAACL&NT
120 W.ASI-INGTON STREET, 3' FLOOR
TF-L (978) 745-9595
F.ii.Y(978) 740.9846
KI\IBERLHY DRISCOLL
A+LALYOR Tmosw ST.PtERRs
DIRECTOR OF Pumic PROPER'IY/BLmnDiG CON IISSIONER
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 1 t 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S I50A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
--- (name of facility)
(address of facility)
st nature of permit applicant
U u 2i - IZ
date
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