7 TAFT RD - BUILDING INSPECTION (3) The ( ornnlo wealth of Massachusetts
f r Huard of Building Regulations and Standards
Y�. Massachusetts State Building Code. 780 CMR. 7"'edition 101'Vll ill'.\I.I ISE
Building Permit Application To Construct. Repair. Renovate Or Demolish a Rrri,r,/./,nmiu, i
One- urTiro-Fu)nilvDitelling
his Section For Official Use Only
!Bui,Id!mg, Permit Number: Date Applied�• �• O� —
Building oni nissiuned nsp ' o Buildings Date
SECTION 1: SITE INFORMATION
LI Property Address: O� 1.2 Assessors Map & Parcel Numbers
�F%
I.la Is this :m accepted Su ee[? yes �i�-nit_ Map Number Parcel \'umher
t..3 Zoning Information: 1.4 Property Dimensions: —
Zoning District Proposed Use Lot Area(sq It) Fron l age(II)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Plot Ld
1.6 Water Supply: tM G.L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone _ Outside Flood Zone'' Munici al ❑ On site dis posal s stem
'Z. ❑
Public ❑ Private❑ Check if yes❑ P I Y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Nan�Print) Address for Service:
/1� g787VXZ5;0;' -
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building ❑ 1 Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Additimi El
Demolition ❑ Accessory Bldg. ❑ Number of Units____ I Other ❑ Specily.
Brief Description of Proposed Work': /1'OD At ONC_S / C C�.t� _
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building S I. Building Permit Fee: $ Indicate hoe fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑'rolal Project Cost' (Item 6) x multiplier x
3. PlumbingS 2
. Other Fees: $
4. Mechanical (HVAC) 8 Lisu
S. Mechanical (Fire S
Suppression) Total All Fees: S
Check No. Check Amount: Cash :\mount:
0. Total Project Cost: Cl Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) A►, J
License Numher Expiration Date
Name ut CSL- IIolder List CSL Typc(see below)
\JJreas T' e- Descririion '
L t:nrestricled (it i u)3i.(X)O Cu. 1'(.)
R Restricted I.e'_ Family Dwelling
Signature M Nlasunry Only
RC RC>idealial Roulingng Cotenue
Telephone \VS Residen(iA \\aiji,w.uld S:Jnig
SF IZesiJemial Solt Puel Bunune A t)Hance lust.dlawai
D Re,idewiai Demolition
5.2 Registered Home Improvement Contractor 0110
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
.igitailire le;irltene - I .—
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. Fat lure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... O No ...........
LI
OSECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
WNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 , 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
�— 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 2ains and penalties of perjury)__
_ 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 Prograrn and
Construction Supervisor Licensing (CSL)can be found in 780 CMR Regulations 1 IO.R6 and I IO.RS. respectively.
'_. 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
Tvpe III cooling system Enclosed
3. 'Total Project Square Footage- may be substituted for "Total Project Cost'
CITY OF SALEM
r
PUBLIC PROPRERTY
pr l ' DEPARTMENT
Ilil: 'I'H- {iA59i ♦ I'd Y: d-9S46
Construction Debris Disposal Affidavit
(re(luired lifr 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 c 40, S 54;
Building Permit 4 _ is issued with the condition that the debris resulting from
this work shall he disposed of in it properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
P'g�e& l
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
_}} signature of permit applicant
date
.Iclu i.�tl,Inc I'�,
I
CITY OF &XI.EM
PUBLIC PROPERTY
DEPARTMENT
KIf01�!�v ruw-ly�
130 Wtivuw.TM STREET 1&MJEK yAaACWSUM 01970
TM-9-W7t5-9S"0 FAX 975-740.9W
HOMEOWNER LICENSE EXEMPTION
Please Print
Date 0512516 Ff
Job Location 1 i/ )c7- �D
Home Owner Address 7 _7W 11_ leAD
Home Owner Telephone-y7k 701 23Z
Present Mailing Address 7 T
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 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 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 "homeowned'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 SIGNATURE .e��� 1�%I
APPROVAL OF BUILDING INSPECTOR
See other side for state code
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