25 SALTONSTALL PKWY - BUILDING INSPECTION The Commonwealth of Massachusetts
� Board of Building Regulations and StandardsSALE CITY OF
Massachusetts State Building Code, 780 Cb1R Revised Mar12011
ilYl Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Family Divelling
This Section For Official Use Only
Building Permit Number: ' e Dat
� Applie
Building Official(Print Name) Signature, Date.
SECTION 1: SITE INFORtMIAT N
1.1 Property Address: 1.2 Assessors Map& Pa Nu bers
z1- SAS (c�J A< c {Pk'=, ) eel
1.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 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.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2:`PROPERTY'OWNERSHH'j'
2.1 Ownert of Record:
D7ame(Prim City, State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK"(cheek all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':__
coca cF 5A4 -.stet: Alt t' �S is
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
[ten ..,
Labor and Materials Official Use Only
1. Building 1. Building Permit Fee $i Indtcaie how fee is determined:
�. Electrical y ❑ Standard City/Town Application Fee
❑Total Pipject Cost' (ltein.6)x multiplier x
3. Plumbing 'S 2 Other Fees: $
4 Mechanical ([[VAC) S List:
5. Mechanical (Fire $
Suppression) Total All Fees: :S
6. 'lbtal Project Cost: S do
Check No. Check Aniount: Cash Amount.
t'� 0 Paid in Pull ❑ Outstanding t3almuc Due:
SECTION S: CONSTRUCTION SERVICES
5.1 Construction Supervisor License (CSL)
License Number Expiration Date
Name of CSL 1-folder
List CSL Type(see below)
— Type. - - Description
No. and Street
U Unrestricted(Buildings up to 35,000 cu. 11)
_ R Restricted 1&2 Family Dwcllin
Cityfrown, State,ZIP bI \klasonr
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
[ Insulation
"rete hone Email address D Demolition
5.2 Registered Hone 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. § 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.
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
contained in this application is true and accurate to the best of my knowledge and understanding..
I'r Owna's or Authorized:\gent's Nannz(Electronic Signannz) � Date
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[order M.G.L. c. I42A. Other important information on the FIIC Program can be found at
www.mass.gov%oca Information on the Construction Supervisor License can be found at www.mass.-o%'r'dps
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.) _(including garage, finished basement/attics, decks or porch)
Gross livin, area(sq. fi.)_ Habitable room count
Number of tiroplaces_ Number of belll'OOInS —
Number Of bathrooms Number of half./baths _
typo of heating system _------ Number of decks/porches --
1'ypeof Cooling System— _ Enclosed_ _Open — _
. total Project Squire Footage" nnay be inbitlnl[cd fill'"Tool Project CoA" --
CITY OF Sm—oof
PUBLIC PROPERTY
DEPAR IENP
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HOMEOWNER LICLNSR EXE.1 njo,V
Pin" plat
Date 4LLIZ �!;,
Job loeatlora
Rome Omar Address •�
Homo Owner Telepboea -e2tT - 3 7--Is
Preaar++t Mailing Address s �
The current esemptioa OPHomaownas"was extended to include owner-occupied
dwellings of MQ Units or feu and to allow such homeowners to engage an individual for
hire who does not possess a license provided that the owner acts as supervise►.
DEFUNIMON OF HO&MOWM
Person(s) *be owns a pierced of Wi d on which hdshe resides or intends to reWde, on
which chars ie, or is intended to bee a one or two tinily dweWng, attached or detached
strucnua accessory to such use and/or farm st nearest, A person who constructs more
than erne 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
OillciaL that hdshe be responsible for all such work performed under the Building
Permit
The undersigned "homeowner'aanunce responsibility for compliance with the State
Building Coda and other applicable bylaws and reSWadcnu
The undmigned "homeowner'certifies that helshe undentasds the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
.vill comply wiih sLd procedures and requirements.
HOMEOWNERS SIGNAMM {
APPROVAL OF 9UILDING 4YSP£ 7CA
See other side for stare code
�+ivr
,r CITY OF SAL.E.M. NL LksSACHUSETTS
7 { P E3t:II.DL\,G DEPAR-M&NT
l3,t 120 W-ASHLYGTON STREET, Y FLOOR.
T EL (978) 745-9595
KIINMERIEY DRISCOLL F•M-Y(978) 740-984d
INLAYOR T140M S ST.PtERRa
DIRECTOR OF PUBLIC PROPER7Y/BUILDOiG CONNISSIONER
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 it 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit f#this work shall be is issued with the condition that the debris resulting from
111, S i SOA. disposed of in a properly licensed waste disposal facility as defined by MGL c
-
The debris will be transported by:
r-) /'Z' ar�zwkf- )
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of Facility)
U signature ofpermit applicant
E1 ?i
date
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