21 THOMAS CIR - BUILDING INSPECTION The Commonwealth of Massachusett=!�
��Board of Building Regulations and StandgOPS
780 EMMassachusetts State Building Code, V YJ�ollBuilding Permit Application To Construct, Repair, Reno
One-or Tivo-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date.Applied:
101 ZZI(S
((1 Building Oilicial(Print Name). Signature Date
1 ION L•SITE INFORMATION'
SECT
1.1 Pr erty ddress: �� G 1.2 Assessors MAP&Parcel Numbers
1.1— this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: IA Property Dimensions:
"Coning District Propose)Use Lot Area(sq R) Frontage(It)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.(j.L C.41t,§34) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yesCl
SECTION': PROPERTY OWNERSHIO
wnert of Record:
2.1FlL�<flC ¢err�y j/i! eq /1r.A— 0/9 70
Q(Print) City,State,ZIP
.Zi lisoo..Rr e ;� Zoe— KbZN u
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKS(check all that Apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work-: /Ze^,a e- H^'A Rr�CG � /roar— fI'yy� �
SECTION 4: ESTtDIATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials) -
I. Building S I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard CitylTown Application Fee
2. Electrical $ ❑Total Project Cosh(item 6)x multiplier x
3. Plumbing S 2?Qther Fees: S
4. Mechanical (HVAC) S List:
i. i\lechanical (Fire S Total All Fees:S
ressiunl
Check No._Cineck Amours[: Cash Amount:
6. 'f tat Project Cust: .S OOb• Ob ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Cortstructimt Supervisor License(CSL)
License Number Expiration Date
Nmne of CSL Holder - List CSL Type(see below)
Type - Description
No. and Street
U Unrestricted BuilJin s tip-to 35,000 cu. 11.
R Restricted 1&2 FamilyDwelling
Cityfrown,State,ZIP M Masonry
RC Rooting 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 Dane
I IIC Cunip:my Name or HIC Registrant Name
No.mid Street Email address
Cit /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 Is3uance of the building permit.
Signed Affidavit Attached? Yes ..........❑ No...........O
SECTION 7a:OWNER AUTHORIZATION,TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTORAPPLIES FOR BUILDING PEP 11T'
1,as Owner of the subject property,hereby authorize
t9 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:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Au rrized Agent's Nai re(Electranic Sigtwture Date
1. An Owner who obtains a building permit to do his t owner who hires an unregistered contractor
(not registered in the Hone Improvement Contractor(HIC) Program);will not have access to the arbitration
program or guaranty rund under NI.G.L.c. I42A.Other important information on the HIC Program can be found at
www.nnass. •oL :'Veil Information on the Construction Supervisor License can be found at ww��dus .
2. When substantial work is planned,provide the information below:
"total fluor 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
"rypeufcoolingsystem Enclosed- Open
3. "Total Project Square Footage"may be substiuuted for,,Total Project Cost"
QT'Y OF SALEM, MASSACHUSE M
BUILDING DEPARTMENT
120 WASHINGTONSTREET,3ADRom
TIEL. (978)745-9595
KIMBERLEY DRISCOLL FAX(978)740-9946
MAYOR TrIOMAS STTIERRE
DIRECTOROF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date 10122,11..5
Job Location ia/ rhd Atef C
Home Owner Address ;Z c/AL
Present Mailing Address 21
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 GF�GCsa— /�llmli
APPROVAL OF BUILDING INSPECTOR
07 Y OF SALEA MASSAaA)SEM
Bu DINGDEPAR7MBNr
120 WAstmlGMS7MT,3IDF"R
7kL(978)745-9595.
%UO FAX(978)741}9846
ERLEYDRISQ7LL
MAYOR 711CUM STYMM
DIRECTORoPPuujcPAorER7r/BumDm ccmmomx
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 8 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:
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
Date