32 SCHOOL ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
tsµ ,iP m OFSALEM
1 Massachusetts State Building Code, 780 CMR, 7 edition
�J Revised dJunmi Janaary
Building Permit Application To Construct, Repair, Renovate Or Demolish a
I \ One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Numb Date Applied:
If
Signature: �—
Bui ding Commissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Pro erty Address: 1.2 Assessors Map& Parcel Numbers
X I 5 r �at,/ 2 eee,•f
1.l a 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 Setback$(R)
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: 1.9 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system
❑
Public❑ Private❑ Check if es❑ p po y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownert of Record: S _ IWO (_f S-dDA,
XName ) Address for Service:
-7sk O p`01-0' Bid? /
Sign re Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied O I Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
N Brief Description of Proposed Work-: r'2
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)s multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S Total All Fees: S
Su ression
n Check No. Check Amount: Cash Amount: -00
6. Total Project Cost: S dQ/ 8W ❑Paid in Full O Outstanding Balance Due:
'a1
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of C'SI.- I folder
I.isI.CSL fype(see below)
Ts pe Description
Address
U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signature I M Masonry Only
RC Residential Routing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
1IIC Company Name or IIIC Registrant Name Registration Number I
Address
Expiration Dale
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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. j
Signed Affidavit Attached? Yes .......... ❑ No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE 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.
Signature of Owner Date
SE/CTIION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I, rvuil //a A 6'-V'4V ,as Owner or Authorized Agent hereby declare
that the stateme s and information on the foregoing application are true and accurate,to the best of my knowledge and
X behalf. I
1.44 rl t—
Prim N
Signature of owner Authonzed Agent Dates
Si ed under the pains 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
(not registered in the Home Improvement Contractor(HIC)Program),will no 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 1 I O.R6 and 110.115, 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 half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
J. "Total Project Square Footage"maybe substituted for"Total Project Cost"
R
CITY OF SALEM
PUBLIC PROPRERTY
1
DEPARTMENT
.., Mlv. 11 !l'T •j,\I I fl, ►t.\K H 1 II J 1...I'r '
I'.u: F111 I:C�t'.1J11\L..V)IM .r /NtA
constructionllDebris
nbl unDxlp'nnovaiuowork) t
(required
d
In accurdatnc with the sixth edition of the State Building Code, 730 CMR section I I I.5
Debris, and the provisions of MGL c 40.S 54:
is issued with the condition that the debris resulting fforn
Building Permit N__�- rl Hcens�d waste disposal facility as defined by MGL c
This work shall he disposed of in properly
l l 1. S 150A.
The debris will be trunsportcd by:
purtle ul'howler)
'1 he debris will be disposed of in
(narrlr ul acr rty
✓l/t ("OS e 'M S-5
.I�nat nt'Ixrmitappbcant
.lase
" CITY OF S.UX.tii
PUBLIC PROPERTY
DEPART NiENT
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HOMEOWNER LICLNSB EXEMPTION
Plow PMst
Data VoLtIZO
Job Locator 3 A 5JL,9o/ 4 .
Home Owner Address E
Homs Owner Telephone a ?
Preboe Mailt°g Addren 'i�� �S/�RA � Q/vt
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 licenser provided that the owner act@ as supervisor.
DEFINMON OF HOMEOWNER
Perwa(s) who owns a parcel of land on which behhe resides or intends to reside, on.
which there is, or is intetded to bs, a one or two family dwelling, attached or detached
structures accessory to such use and/or farm structure. 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
Officiak that he/she be responsible for all such work 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 inWation p ures and requirements and that he/she
will comply with said procedure and requi a
HOMEOWNERS SIGNATURE
.APPROVAL OF BUILDING NSPECTOR
See other side for state code