6 TREMONT ST - BUILDING INSPECTION r �
The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
. � Massachusetts State Building Cale, 780 CMR, T"edition isemeopw
Builds
ng Dept
Balding Permit Application To Construct. Repair, Renovate Or Demolish a
One-or riro-familt,Dueffing
This Section For Official Use Only
Building Permit um c Date Applied: t �i ` 6•�
_J Signature: / l—
Buildi Commissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
1.1 a Is this an acce led street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(R)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40.154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Public O Private O Check if sI3 P po y
SECTION 2: PROPERTY OWNERSHIP'
IC)
o4AJ l l l_ OA3 7
IPrial) Address for Service:
9q8 �45 63
re Telephone
SECTION l: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
onstruction O Existing Building O Owner-Occupied O Repairs(s) O Alteration(s) O Addition O
ition O Accessory Bldg. O Number of Units_ Other 0 Specify:
escription of Proposed Work':
O .� l,� VkJ 0-0 7 T is -+— A-z2 TO
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
labor and Materialsing S I. Building Permit Fee: S Indicate how fee is determined:O Standard City/Town Application Fee
cal S O Total Project Cost(Item 6)x multiplier x
bing S 1. OtherFees: fanical (HVAC) S List: xxo1 !/
t Mechanical (Fire S Total All Fees: S
Su resswn
�^ Check No. _Check Amount: Cash Amount:
6 Totd Project Cost: S Soya 4 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Comtruction Supersisor(CSL)
..
Imu
Number Esprrabon Dutt
Nyoe of CSL Hylder CSL Type I h
ec clow) Dean tion
AJdmsf Unrestricted u to)3,000 Cu. Ft Restricted Ih2 Famrlsitinature .Mason Only
RC Residential Roofing Coverin
Telephone wS Residential Window and Srdm
SF Residential Solid Fuel Burning Appliance Installation
D I 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.I. c. 152.1 2SC(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........... O
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 as Owner of the subject property hereby
authorize to act on my behalf,in all mattm
relative to work authorized b this building permit application.
AQ r 4�0
i nature of Owner Date
SECTION :OWNERu OR AUTHORIZED AGENT DECLARATION
1, , as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application arc true and accurate, to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
St tied under the pains and penalties of perjury)
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 gg have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations I l0.R6 and I MRS. respectively.
2. When substantial work is planned,provide the information below:
2Toui floors 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 halfbaihs
Type of heating sysrem Number of decks/ porches
Ty pe of cooling systern Enclo.ed Open
3 Total Project Square Footage" may he.uh,tituted for *Total Project Cost"
CITY OF &UE3 t
PUBLIC PROPERTY
DEPARTMENT
Kl L
NAVOS 130 wAaun[.TON S77FiT•SALM NA9AO/LSVM 01970
741.97.8.7154S" • FAX 976.740-984
HOMEOWNER LICENSE EXEMPTION
Pieria Print
Date
Job Location 6 TZ 2A-C ok-3 7— e
Home Owner Address
Home Owner Telephone 9 -4 S a g a --+63 4
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
lure 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 helshe 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 SIGNATURE �n7
.APPROVAL OF BUILDING INSPECTOR
See other side for state code