21 SALTONSTALL PKWY - BUILDING INSPECTION (4) The Commonwealth of Massachusetts dAO '
Board of Building Regulations and Standards DNS Grl�h M/ Massachusetts State Building Code, 780 CMR CES
Revised,NBuilding Permit Application To Construct, Repair, Renovate Or Demolish�� NOY 122l
One-or Two-Family Dwelling
This Section For Of Icin a OnlBuilding Permit Number: Date plied-Building ORicial(Print Name). Signature . . D
SECTION t:SITE INFORMATION`
Ll Property Address: 1.2 Assessors hlap&Parcel Numbers
zi J�rT� 9ss+�LC PKw"1
I.I a Is this an acce ted street?yes ✓ no Map Number Parcel Number
1.3 'Coning Information: 1.Z ooty Dimensions. 3 - r7—
"Coning District Proposed Use Lot Area(sy it) Frontage(II)
1.5 Building Setbacks(ft)
Front Yard - Side Yards Rear Yard
ReyuireJ Provide) Required Provided Required Provided
1.6 Water Supply:(M.O.L c.ye,§54) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Public Fd Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if es❑
SECTION2: PROPERTY OWNERSHWP
2.1 Owners of Record:
JTOHro ' t=55 SAGE � , �.� .D r4 � O
�me(Print) ,r City,State,ZIP
( cr2. )17716K ,Jh— t_21'
No.and Street Telephone Email AJJrvss
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building O Owner-Occupied Er I Repairs(s) El I Alterations) O Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work : �syc�es F a.�� C7w[r +vArr
� H A
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ Dp0 I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(item 6)s multiplier s
3. Plumbing $ !�(,ether Fees: S
d.Mechanical (hIVAC) S List:
5. Mechanical (Fire S Total All Fees:S
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: -S ��•Osl,��' ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Sd)icrvisor License(CSL)
License Number Expiration Dale
N;une ofCSL tluldey°"'" List CSL'rype(see below)
�. ,
Type . , Description
Nu.:nd Street
U Unrestricted Buildtn s tip to 35,000 cu. 11.)
R Restricted 1&2 Family Dwelling
Cilyfrown,Slate,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone. Email address I Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Dale
IIIC Comp:my Name or HIC Registrant Name
No. and Street Email address
City/Town, State ZIP Telephone
SECTION 6:WORKERS'CONIPENSATION 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 ..........Cl No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE CONIPLETED WHEN.' i .
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,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.
�15tir-� I—trAQlco�g.S s ! / /
Print Owner's Name(Electronic Signature) Uate
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information
contained in
iin this application is true and accurate to the best of my knowledge and understanding.
Prin wner's or Authorized Agent's Name(Electronic Signature) —mute
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 I.G.L.c. 142A. Other important information on the HIC Program can be found at
wvvw.mass.,,ov�!oca Information on the Construction Supervisor License can be round at wwvv.mass.uov'dos .
2. When substantial work is planned,provide the information below:
Total floor area(sq. R.) .(including garage, finished basementlattics,decks or porch)
Gross living area(sq. 11.) 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
.l. "rfoml Project Square Footage"may be substituted lox"Total Project Cost"
CITY OF SALEM, MASSACHUSETTS
BUILDING DEPARTMENT
71' ' �"%! 120 WASHNGTON STREET,3"D FLOOR
\ TEL. (978) 745-9595
FAX(978) 740-9846
KINIBERLEY DRISCOLL
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date 1162-
Job Location z( S,4�ta.✓sT.s� P� w /
Home Owner Address
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.
HOMEOWNER'S SIGNATURE /�_�
APPROVAL OF BUILDING INSPECTOR
CITY OF SALEM, MASSAQHUSEM
BUILDING DEPARTMENT
120 WASHINGTON STREET 3/D FLOOR
TEL. (978)745-9595
FAX AX(978)740-9846
MAYOR THomAS STTiERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMNIISSIONER
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# 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:
Avy P€-4—
(name of hauler)
The debris will be disposed of in:
k2-3 ezor rnw-L
(name of facility)
(address of facility)
Sig
nature of applicant
v Date