18 SCENIC AVE - BUILDING INSPECTION gz-7q-I 1
S The Commonwealth ofMassachusetts RECEIVED CITY OF
Board of Building Regulations and SthiSda {sTIONAL SERVI ES SALEM
Massachusetts State Building Code,780 CMR Revised Mar 2011
Building Permit Application To Construct,Repair,Re tA*Ipe3DOAh 2
One-or Two-Family Dwelling
This Section For Official Use Only
^ Building Permit Number: Date plied:
Building Official(Print Name) - Signature Date
SECTION 1:SITE INFORMATION
Ln ].1 o er Aress: 1.2 Assessors Map&Parcel Numbers
Lla 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)
`r 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❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check ifyes❑
SECTION 2: PROPERTY(OWNERSHIP,'[ q F
2.1 wner'�Record•
ame(Print) City,State,ZIPS
No.and Street Telephone Email Ad
SECTION 3:DESCRIPTION OF PROPOS WORK=(check all that apply)
New Construction❑ Existing Building I Owner-Occupied ;Repairs(s) ❑ Alteration(s) ❑ Addition ElDemolition ❑ Accessory Bldg.❑ Number of UnitsOther ❑ Specify:
Brief Description of Proposed Work :
e o A
c
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 3 S__�) 0 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ j D d ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ D Q 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
u ression Total All Fees:$
ob Check No. Check Amount: Cash Amount:
6. tal Project Cost: $ �'�t a�,P �p O O Paid in Full ❑Outstanding Balance Due:
1Vl t I..E'CD g 1 $
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
Lis[CSL Type(see below)
No.and Street TYPO I Description.
U I Unrestricted(Buildings up to 35,000 cu.ft.
City/Town,State,ZIP R Restricted I&2 FamilyDwelling
M I Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Buming 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
Ci /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 Tar OWNER AUTHORIZATION TO HE 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:.OWNE W 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 tine and ate to the best of y knowledge and understanding.
81 l�
Print Owner's or Ay4borized Ag ame(Ijlec tcsign ) 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
w1+nv.mass.eov,'oca Information on the Construction Supervisor License can be found at www.mass.eov/dys
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"
aCITY OF SALEM, MASSAC�IUSETTSBUILDINGDEPART MNT
120 WASHINGTON STREET,3RRooR
TEL. (978)745-9595
KIIvIBERLEYDRISOOLL FAX(978)740-9846
MAYOR TYiOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date $ /3
Job Location 1 3� SGervlc AYC Sa (P—r�w,* ( 7
Home Owner Address— J e4l'(G /7qqVL . Sc IZsM
Present Mailing Address 4me alpe
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 I SPECTOR
CITY OF SALEK MASSACHUSEM
r'
Burl.DnaG DEPARTnaNr
120 WASHINGTON STREET,31D FLom
UL(978)745-9595.
KRaERLEYDRISOJLL FAX(978)740-9946
MAYOR THcmAs STYmRRB
DIRECTOR OF PUBIICPROPERTY/BtU DM 03SSIOMR
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:
(name of hauler)
The debris will be disposed of in:
(name of facility).
(address of facility)
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