28 SCHOOL STREET CT - BUILDING INSPECTION The Comntonwcallh of Massachuscits
Board of Building Regulations and Standards T
own
Massachusetts State Building Code, 780 Ch1R. T"edition
Budding Permit Application To Construct. Repay. Renovate Or Demolish a
One. or 7hco-Funish Dwelling
This See ton For Official Use Only
Building Permit Number: a pplicd:
Signature:
Building Commtsyt at/ nspector of Date
SE TIO :SITE INFORMATION
1.1 Property dress: 1.2 Assessors Map& Parcel Numbers
S D L
1.1 a Is this an accepted sheet:'yea no Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use La Area(sq It) Frontage(tt)
1.5 Building Setbacks(It)
Front Yard Side Yards Rev Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L C.40.154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O tht site dispoad system O
Public O Private O Cheek if es0
SECTION 2: PROPERTY OWNERSHIP'
1 Owe III.
=--)�SG ` b,
c
Address for Service:
X (Print q-leg :SzG
cure Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction O Existing Building O Owner-Occupied O Repairs(s) O 1 Alteration(s) O Addition O
Demolition O Accessory Bldg. O Number of Units_ Other O Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: ORlelad Use Only
Labor and Materials
1. Building f 1. Building Permit Fee: f Indicate how fee is determined:
O Standard City/Town Application Fee
2 Electrical f O Total Project Cost'(Item 6)x multiplier x
7 Plumbing f 2. Other Fees: S �
4. Mechanical IHVAC) f List: IL4 P6�
s Mechanical (Fire f Total All Fees. f
Su remon
Check No. _Check Amount: Cash Amount:_
h Told Protect Cosf. f Paid in Full 0 Outstanding Balance Due:
SECTION S: CONSTRUCTION SERVICES
3.1 Licensed Construction Superxisor(CSL)
'• L.ccnw Number Expiration Date
N.4rna of CSL- Iigkkr Lid CSL Type(,ec beluw)
Ts or I Description
Address
U Unrestricted i up to)5.000 Cu. Ft.
R Restricted Ih2 Family D%ellinst
Signature M Mawnry Only
RC Rcvdcnnal flooring Covering
Telephone W'S Residential Window and Sidra
SF I Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
3.3 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 132.1 23C(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'.r Yes.......... O No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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.
Si nature of Owner Date
SECTI :OWNER'OR AUTHORIZED AGENT DECLARATION
�a1, � ,as Owner or Authorized Agent hereby declare
that the statements and informati n on the foregoing application are true and accurate,to the best of my knowledge and
alE
r
Sin o Owner or Authorized Agent Date
Si under the aim and penalties ofperjury)
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 W have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations I I0.R6 and I IO.R3, respectively.
2. 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 halfbaths
Type ofheating system Number of decks/porches
Ty pe of cooling system Enclosed Open
3 "Total Project Square Footage" may he substituted for 'Total Project Cost"
R
CITY OF S.kLEM
PUBLIC PROPERTY
- - DEPARTMENT
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HOMEOWNER LICENSE EXE-NMION
Mass trot
Date
Job Location �� S
Home Owner Address
Home Ownar Telephone 1"
present Mailing Address
The current exemption of"Homeowners"was extended to include owner-0ccupied
dwellings of two Units or less ad to allow such homeowners to engage an individual for
hire who.does not possess a licaus,provided that the owner acts L supervisor.
DEFINMON OF HOMMOWNML
person(s) who owns a pareel 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 construct@ more
than one home in a two year period shall not be considered a homeowner. Such
1.homeowna"shall submit to the Building O®cial,on a form acceptable to the Building
Ot'Ncial, 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
Will comply with said procedures and requirements.
X HOMEOWNERS SIGNATURE
.APPROVAL OF BUILDING DiSPECTOR
See other side for state code