2 THOMAS CIR - BUILDING INSPECTION zS : �-
The Commonwealth of Massachusetts
CY OF
f Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
'n One-or Two-Family Dwelling
t` This Sectaon For Official,Use Only
n Building Permit Number.. Date pied;
I J In
Building Official(Print Name) Signature- Date
SECTION 1:SITE INFORMATION
.1 roperty Address: 1.2 Assessors Map&Parcel Numbers
,;)- -( � 0 met_f (�_,
L 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 ft) Frontage(ft)
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? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION PROPERTYOWNERSHIP'
2.1 Owuer'otRecord: _ - .... .-.
Name(Print) City,State,ZIP a r!1
No.and Street Telephone Q ' Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(eheck all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
(� Brief Description ofProposedWorV:
�pQlat
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire Suppression)
$ Total All Fees:$
-
,�1 UU Check No. Check Amount: Cash Amount
6.Total Project Cost: $ �v 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES 1
5.1 Construction Supervisor License(CSL) "
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Descoption.
U Unrestricted(Buildings up to 35,000 ca.ft.
R Restricted l&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone 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
Ci /Town State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION UVV, ANCE 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...........❑
SECTfON 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S >GF}NT OR CONTRACTOR APPLIES FOR Bi)II DING 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 her3byattest under the pains and penalties of perjury that all of the information
contained in thiViais accurate to the best of my knowledge and understanding.
Print Owner' ed Agent's a(Electronic Signature) lbrite7
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
�♦ww.mass.gov;oca Information on the Construction Supervisor License can be found at www.mass.gov/dns
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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"
QTY OF SALEM, MASSACHUSETTS
a rJ BUILDING DEPARTMENT
3 120 WASHINGTONSTREET,3"DFLOOR
tr
TEL. (978)745-9595
FAX(978)740-9846
KIMBER.LEY DRISOJLL
MAYOR TY-IOivfAs ST.PIERRE
DIRECTOR OF PUBLICPROPERTY/BUILDING CON I ESSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date / r
Job Location d-
1
Home Owner Address So Mr4
Present Mailing Address /Zr M-
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