20 SYMONDS ST - BUILDING INSPECTION Tr3- f - 3 i -'-70 CA514 .
The Commonwealth of Massachusetts
°u?d OF
Board of Building Regulations and Standards CITY M
Massachusetts State Building Code, 780 CMR RECEIVED SdMar
f�{ qFR j�vigedMar201/
Building Permit Application To Construct,Repair,Renag%TNAi Hilsl 1, L
One-or Two-Family Dwelling
This Sect on For Official Use Q311,1111 AUGI
Building Permit Number: D`a+tle�Appied:
Building Official(Print Name) igna Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1 1.2 Assessors Map&Parcel Numbers
1.1 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 ft) Frontage(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?
Check ifyes0 Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 er'of Record: Ip /
norin TQ r'rc� c, I PVVl f�c� l `1
Name(Print) City,State,ZIP
���� 978-g,SZ -3309
No.and treet Telephone mail dddress
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief��,��, ''Descrip ion of Proposed Work:
n I A s-P
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials -
l.Building $ I 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:_ G vll; 8 5 3 2- 1
5.Mechanical (Fire $ —
Suppression) Total All Fee :$
h Check No. Check A Cash Amount:
6.Total Project Cost: $ it)) wo ❑Paid in Full ❑Outstanding Balance Due:
c� TO
SECTION 5: CONSTRUCTION SERVICES
rConstruction Supervisor License(CSL)
J
License Number Expuation Date
der
List CSL Type(see below)
I Type Description
1 t.UA gig U Unrestricted Buildin s u to 35,000 cu.ft.)
Ctty/I'own,State,ZIP R Restricted 1&2 Family Dwellin
M Maso
RC Roofin Co-
ws Window and Sidi-
SF Solid Fuel Burning Appliances
I Insulation
Tele hone 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 i
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 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.
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
conta contained in this applic ton is tru d accurate[o the best of my knowledge and understanding.
Print Owner's or Authorized Agen�s Name(Electronic Signature) 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
www.mass.eov,loca Information on the Construction Supervisor License can be found at www.niass,,-,ov/df)s
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"
i
CITY OF SALEM, MASSACHUSETTS
BUILDING DEPARTMENT
120 WASHNGTON STREET,31O FLOOR
TEL. (978) 745-9595
FAx(978) 740-9846
KINIBERLEY DRISCOLL
MAYOR THOiVIAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDINGCOMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:p
Date f
Job Location ��1�.� �n�� �o l= c�,
Il it
Home Owner Address
Present Mailing Address
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 INSPECTOR
CITY OF SALEM, MASSACHUSEM
BUILDING DEPARTMENT
120 WASHNGTON STREET,3m FLOOR
`�rn TEL. (978)745-9595
KIMBERLEY DRISCOLL FAx(978)740-9846
MAYOR THomAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
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:
l Q -e cLz LLSL
6/(narne of hauler)
The debris will be disposed of in:
anne of facility)
(address of facility)
Signature of applicant
Date