6 SKERRY ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Town of
Board of Building Regulations and Standards s
oa� Massachusetts State Building Code, 780 CMR, 7"edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
�re or Ttto-Family Dwelling
This Section For Official Use Only
Building Permit Number, L_____L_g Date Applied:
Signature: W��
Buddi g, ornmissioncr/InskFjp of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
kc -,)r't°Sf <-! S� ' - Parcel Number
1.1 a Is this an accepted s reett '?yes_ no_ Map Number
IJ Zoning Information: _ _ _ 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq fit) Frontage(R)
1.5 Building Setbacks(ft)
Side Yards Rear Yard
Front Yard
Required Required Provided Required 7system
1.6 Water Supply:(M.G.L c.401 154) 1.7 Flood Zone Information: "Sewage Disposal Sy
Zone: _ Outside Flood Zone? Municipal ❑ On site dispo
Public❑ Private❑ Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Recgrd*_ t //�Q
Ma ,f t- 1 P rt 1Li t 2 k ` 12 w � Address for Service:
Name(Print)
�`e 9.19 -4S
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check 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':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building E 1. Building Permit Fee: E Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical 5 ❑Total Project Cost' Ite 6)x multiplier x
3. Plumbing 5 2. Other Fees: E
X 4. Mechanical (HVAC) 5 List:
5. Mechanical (Fire 5 Total All Fees: S
Suppression)
5 C ck No. Check mount: Cash Amount:
6. Total Project Cost: E t Q60 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) t
License Number Expiration Date
N;)me of CSL-Hplder
List CSL Type(see below)
Address Type Description
U I Unrestricted(up to 35,000 Cu. Ft.)
Signature R Restricted 1&2 Family Dwelling
M Nlasonry Only
RC Residential RoofingCovering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 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.c. 152.4 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 .......... O No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the ro 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: OWNER'-OR AUTHORIZED AGENT DECLARATION
1, , as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and 2enaltics ofperjury)
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 no 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 780 CMR Regulations I IO.R6 and 110.RS, 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"may be substituted for"Total Project Cost"
CITY OF S.0 EM
PUBLIC PROPERTY
DEPARTMENT
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Ts-97L745-95"• FAL 971-7469"
HOMEOWNER LICENSE E)MMPTION
Please Print
Date 3 ' I 0 ' v cA
Job Location CL 1
Home Owner Address
Horne Owner Telephone Q 78•-7 4 9 •74 7 q-.
Present Mailing Address
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 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 fors 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNAMME
APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SALEM
l lay ' PUBLIC PROPRERTY
•`�' .) '
DEPARTMENT
I I I- V-B '4;.'):4; • 1 U ')'.i '4:Vi4,.
Construction Debris Disposal Affidavit
(rcyuked lbr all demolition and renovation work)
In accordance k�ith the sixth edition of the State Building Code, 7S0 C'b9R section 1 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit N is issued with the condition that the debris resultin.- from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I11. S 150A.
The debris will be transported by:
(name Lit hauler)
I he debris will be disposed of in
(namr ul laeility)
(addresv of Iacilily)
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HL'llal Ul l' of p:nnn upphcant
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