25 SALTONSTALL PKWY - BUILDING INSPECTION (3) A The Commonwealth of Massachusetts
/1 Board of Building Regulations and Standards CITY
try' J Massachusetts State Building Code, 780 CMR, Vh edition OF SALEM
Revised Junuury
J Building Permit Application To Construct,Repair, Renovate Or Demolish a 1, :008
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Signature: r4
Buildin Commissioner/Ins t to uil rags Date
SE TION 1:SITE INFORMATION
I.1 Prop"Address: V 1.2 Assessors Map& Parcel Numbers
nLlb iSFAu• j2kV.`J
I.la 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(it)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Requited 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 es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
Name(Print) Address for Service:
Si rc Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Descrip�ion of Proposed Work':
,x dcz 2r3TZ�0 L )oaf) �� fPla2 J/t
Cc)L=.2p, `xAS
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Olficfal Use Only
Labor and Materials
I. Building S 1. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑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
6.Total Project Cost: S Check No. Check Amount: Cash Amount:
❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
I.icense Number Expiration Date
Name of CSL-Ifolder List CSL'I'ype(see below)
fy PC Description
Address U unrestricted u to 35,000 Cu.Ft.
R Restricted IR2 Fa I Dwelling
Signature M Mason On!
RC Residential Roofing Covering
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or 111C Registrant Name Registration Number
Address Expiration Date
Signature 'relephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 2SC(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...........13
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
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1 ,as Owner or Authorized Agent hereby declare
that the st tements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
i TDN to riTuo��
P1 nt N
( lGa
Signature )wner or Authorized Agent Date
Si ed u er the sins and penalties of 'u
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(no(registered in the Home Improvement Contractor(HIC)Program),will Mol 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 I IO.RS,respectively.
?. 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
). "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF S.UY.Ni
PUBLIC PROPERTY
DEPARTiMENT
Vwvo� 130W.mu1w.1MSn aT9SourocVAnAOILSC t01970
rtL 97a.715-9$"•F...c 97L74&964
HOMEOWNER LICENSE EXEMPTION
Ptew lrlit
Dam
Home Owner Address 0<- S.41_, 'Pa�T✓I Pcc.J�r
Home Owner Telephone !j2L �D�P— 417cl-
Present Mailing Address a f sAt tt wfiv'Aw Gi��}�
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or leas 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 them 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 wort performed under the Building
Permit.
The undersigned "homeowner"assume@ 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 INSPECTOR
See other side for state code
CITY OF SALEM
PUBLIC PROPRERTY
jN b
�• DEPARTMENT
1'JI: MI f I ''Mlv,'41
•)•111 fl, Jt.1�i 11 111 .1 I,•.I'i'.
IYI.9ry 7J}.9i4s 0 1:%X:'J7(♦JJY17x,
Construction Debris Disposal Affidavit
(required lur all denolition anJ renovation work)
In accordance with the sixlll edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL a 40,S 54;
Building Permit 0 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
t l 1. S 150A.
The debris will be transported by.
pmtne ul'hauler)
The debris will be disposed of in :
(IIWW of Mobrty
t aJJmll ul'I'x 4ity1
I�nmure of lwrmit.lpplicant
date