11 PYBURN AVE - BUILDING INSPECTION (4) O •
The Commonwealth of\4assachusetts
�- Board of Building Regulations and Standards CITY OF
RR Massachusetts State Building Code, 730 Cb1R SALEM
Revised Mar 2011
dLJ Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Family Dtivelling
This Section For Official Use Only
Building Permit Number - Date Ap h
i
Building Official(Print Name) '.Signature - ate
SECTION I: SITE INFORtNG1TI
1.1 Property Address: 1.2 Assessors Map & Parcel Numbers
1.1 a Is t is 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:
Zone: _ Outside Flood Zone?
Public(� Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2:; PROPERTY OWNERSHIPL:'
2.1 Ownertof ecord: Cam, a
P 6- O �y
RAA t"1
Nan le(Print) City,State,ZIP
I'1 PWAY=n l qI3 ' , 2'�<7t w
No.and re t Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Build ng ❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1Accessory Bldg. ❑ Number of Units Other Ig�specify: CAC—
Brief Description of Proposed Work:
Z') (VQE 1 11b -C AA 4 /. A il-Ok ot-w-)
iY)�7b _12 a+-
SECTION 4: ESTINL4TED CONSTRUCTION COSTS-
Item Estimated Costs: Official Use Only...
Labor and Materials
1. Building S 5V 1..Building PermitFee:J Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. F,lectrical $ ❑ y - - -
"Cotal"Project Cost. ,(Item b)xmultipGer. x
3. Plumbing 4 2. Other Fees: S
I Mechanical (IIVAC) 3 List:
i, \(«huu al (Fire $
�ii > iressiun) __
Total All Fees: tS
Check No. Cheek Amount: Cash Amount:
(1. Total Project Cost 5 0 Paul in Full ❑ Outstanding Balance Duo:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL I[older
List CSL Type(see below)
No. and Street Type Description -
U Unrestricted Buildin s u to 35,000 cu, 11.
R Restricted 1&2 F.unil Dwellin
Citylrown, State,ZIP NI blasonr
RC Roofm Coverin
\VS Window and S"I
SF Solid Fuel Burning Appliances
I Insulation
relz hone Email address D Demolition
5.2 Registered Home Improvement Contractor(111C)
MC Registration Number Expiration Date
I IIC Company Name or MC 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 her r the pains and penalties of perjury that all of the information
contained in this application is tr d curate to the fmy knowledge and underst7*T/6
---( psi` A --
1'rint Owner's or Aut�ed:\ •nt's Nam (Electronic 4 nature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(nut registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty find under M.G.L. c. 142A. Other important information on the HIC Program can be found at
w ww.ma;c.< uvhxa Information on the Construction Supervisor License can be found at�eww.urtss.,.u�:'dL
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.)-_ _(including garage, finished basement/attics,decks or porch)
Gros, living❑rca(sq. 11.) habitable room count
Number oftireplaces Number ofbedrooms -_-- —__—_--
?lumber of bathrooms Number of halt ib:uhs _
----------
Type of hemiug system - -_ _ _.-- Number of decks/porches --______---
F)pe of cooling sy;ion--------.._—__—_--- E:nclused---_ ---- —open _ —---
}_ '_I_>Lil I'nye<t tiyuare Footage" inuy beub,htuwd t_i-- Iht_tl I'rulect Cost -- -
CITY OF SMYL NI
PUBLIC PROPERTY
DEPARTMENT
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HOMEOWNER LICLNS6 EXE.MMON
Ptew platy
Date
!ob Laeadar•
Homy Owner o l
Home Owner Telephone
Prosant Mailfag Address
Ths current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or lose and to allow such homeowner*to engage an individual for
hire who.does not possess a gcmwl provided that the owner acts as supervisor.
DEFiNMON OF HOMEOWNER
Person(s) who owns a pared of lead an which Wshe resides or intendo to reside.on
which there is, or is intended to bs, a one or two family dwelling, attached or detached
structures accessory to such use and/or farm stiuetureL A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeownd'shall submit to the Building OQleial,on a form acceptable to the Building
Oilleial, that helsho 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,
no undersigned "homeowner"certifies that he/she understands the City of Salem
Building Department minimum don procedures and requirements and that he/she
will comply with said procedures entl.
HOMEOWNERS SIGMA
APPROVAL OF BUILDING [NSPECTO
See other side for state code