28 TREMONT ST - BUILDING INSPECTION (4) The Commonwealth of Massachusetts
j r Board of Building Regulations and Standards �E EIYE CITY
OF
4 / Massachusetts State Building Code, 780 CMR INSPECTIONALAERMIMSi
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling
This Section For Off Al Use Only
Building Permit Number: D e Applied: -
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
I.I a Is this an accepted street?yes no Map Number Parcel cel 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 System:
Public Zone: _ Outside FloodZ e?
Private❑ Check if yes Municipal On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP`
2. Owner of Record: / C
JOOo-r /4/ t�`SOi..rPllam. SLrk'M. r I�'I 0/70
Name(Print) //r City,State,ZIP n /
�``� '�/YMo�✓1 97B'-spa-r`.�y/ yriPS dial f'/Cns�ew
an �f
No. d Street "Telephone t E ail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied 0 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition 01Accessory Bldg. ❑ Number of Units Other ❑ Speedy:
Brief Description of Proposed Work': o r -I;e,.� q `-
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ I. Building Permit Fee: $ Indicate how fee is determined:
❑Standard Cityfrown Application Fee
2.Electrical $ ❑"total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (FIVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 3 v, 0o ❑ Paid in Full ❑Outstanding Balance Due:
(01a I CIIa&,,-� Ik P,u `1 Lmonn
SECTION 5: CONSTRUCTION SERVICES ,
5.1 Construction Supervisor License(CSL)
I . - t,
License Number Expiration Date
-Name of CSL Holder
List CSL Type(see below)
o.and Street — Type Description
U Unrestricted(Buildings up to 35,000 cu. ft.)
R Restricted I&2 FamilyDwelling
City/I'own,State,ZIP M Mason
ry
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 Num her Expiration Date
HiC Company Name or iilC Registrant Name
No.and Street Email address
City/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
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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 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 Authorivzd Agent's Name(Electronic Signature) Dare
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 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
)vww.mass.¢ov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
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"
CITY OF Siuz. I, itiLxSSAC
�'. HUSETTS
8L:=LNr,DEPaaTatENT
130 W."HLYGTON STREET, Y*FLOOR
Tt..L (973) 745-9595
Rux(978) 7-10-984S
(Ct1[BERL.fiY Dt7ISCOf1.
&LAY01 T11O.%LAs ST.Pmgaa
DIRECTOa OF Pt;BLIC PR0PERTy/8L:MDLNG CONL\tl»IO'NEZ
Construction Debris Disposal affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 C&IR section l l 1.5
Debris, and die provisions of tNfGL c 40, S 54;
Building Permit tf is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by tNIGL c
l 11, S 150A.
The debris will be transported by:
y�r��N �5a r0 (�
(,,Ai(:of hauler)
The debris will be disposed of in ;
C (name of Favaity)
1 Ileol
(�dJress of raeility) �
signatureufpemitapplicant
Luc --
CITY OF SALEM, MASSAC HUSETTS
BUILDING DEPARTMENT
r jf 120 WASI-IINGTON STREET,31D FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KINMERLEY DRISCOLL
MAYOR TI-Io"STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date
Job Location .9$ J^Crie Sii�ill
Home Owner Address Or ✓l 10e.,Lgla A4 d/,
Present Mailing Address 1? Fff,-�,Ay Ofa ,.e &bd� q mo- ail&a
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'SSIGNATUR�-- Irbl'V �SHI"
APPROVAL OF BUILDING INSPECTOR