10 TURNER ST - BUILDING INSPECTION (2) i The Commonwealth of blos.c�p�e��t ECEIVEU
Board of Building Regulations and1ltStStl�12MAL SERVICEERevisedifar
F
� � Massachusetts State Building Code, 780 CMR
m y�� p 2011
�- Building Permit Application To Construct, Repait"Add9'dte�AoMaR
One-or Avo-Family Dwelling
This Section For Official Use Only
ti Date A Reds
B
uilding Permit PP
3Jf�/l�
t s mare
_^ 0tliciai(Print Name). _ - _ -
SECTION It SITE INFORMATION
ert�tA,ddrre E �� S Rl� p� 1.1 Assessors Alnp.4t Parcel Numbers
Xthis an accepted street?yes_ no , ` Map Number Parcel Number
ng Information: 1.d Property Dimensions:
strict Proposed Use - Lot Area(sq 11) Frontage(R)
ingSetbacks(R)
Front Yard - - Side Yards Rear Yard
Required Provided Required -- Provided. . Required - Provided-
1.6 Water Supply:(M.G.L e.40,§Sd) 1.7 Flood Zooe Information: 1.8 Sewage Disposal System:
Public❑ Private O. Zone: _ Outside Flood Zone? Municipd O On site disposal system ❑- -
Check if es❑
SECTION 2: PROPER',TYOWNERSRIP!`
2.1 Ownerr of Record:
N/{ r(I c rFlF E Wtt�F L-t t2 S fc t✓E.vt }O
'fan (Print) Lit State,ZIP
IU ToF-Nt2 S T (alfi2t� I6(�2 ktnnswe ConrCk
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK°(check all that apply),
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) O 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
B"riS�fDescriptionofPraposedWork-: {Rt( �96L) r ClniMna2 I-LStew A WOo
Stage- ito m k- v tc-t e I" 20o25 L ex- twW se-C Ina tt�
a-v a VLee ar. WL5 s=c-k-; ay-\
t A V- r otit • Closter iS
-( C-tF 2G1 �t(o .
SECTION 4: ESTIMATED CONSTRUCTION COSTS Na.p 6lrLm S{zw e -
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ 1, Building Permit Fee:S Indicate how fee is determined:
❑Standard City/fown Application Fee
2. Electrical S ❑Total Project Cost'(item 6)x multiplier x
J. Plumbing S 2?PtherFees: S ��\ 7(
a.Mechanical (FIVAC) S List: CJ ( )
5. Mechanical (Fire S Total All Fees:S
Su ression)
Check No. Check Amount: Cash Amount:
X 6. Total Project Cost: S 3 t 5 D D @ ❑Paid in Full ❑Outstanding Balance Due:
ito 1-0D$
�Atl� 3� 11
t z�r ..-
'IS' CT EION 5: CONSTRUCTION SERVICES 1 u.i
5.1 Constructian Sdi�civisoi Lieense`(CSL) `
License Number Expiration Date
Name ofCSL Holder tt f "^ '" �'� "" ""1
List CSL'Type(see below)
Type. - Description .
No.:md Scree[
U Unrestricted uildings up to 35,000 cu. It.
R Restricted 1&2 Family Dwelling
Cityfrown,State,ZIP M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I I Insulation
-Telephone Email address I D Demolition
5.2 Registered home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.mid Street - - Email address
-City/Town,State ZIP Tel e hone
SECTION 6:WORKERS'.COr IPENSAT[ON INSURANCE AFFIDAVIT(M:G.L.e.I5Z.§ 2$C(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 Isivance 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
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Nance(Electronic Signature) Date
SECTION 7b:OWNER!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 th' application is true and accurate to the best of my knowledge and understanding.
Print Owncr' or Authorized Agent's Name(Electronic Signature) Date
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 ad have access to the arbitration
program or guaranty fund under M.G.L.c. 142A. Other important information on the-MC-Progiam can be lounn �t
www mass e000ca Information on the Construction Supervisor License can be round at+vww.mass.^_ov/dux
2. When substantial work is planned,provide the information below:
"rota( floor area(sq. ft.) 'r (including garage, finished basement/attics,decks or porch)
Gross living area(sq. 11.) 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. "rural Project Square Footage"may be substituted for"Total Project Cost"
1
' QTY OF SALEM, MASSACHUSE TTS
BUILDING DEPARTMENT
120 WASFRNGTON STREET,3" FLOoR
.sty TEL. (978)745-9595
F
KIMBERLEYDRIS�LL FAX(978)740-9846
MAYOR THOMAS STTPIERRE
DIRECTOR OF PUBLICPROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT.,
3 ( 4 a01
Date t �
Job Location l C) 1 U V v\,-f-V
Home Owner Address ( () l y V (n 2✓ s S cal eM
Present Mailing Address 1() l`�V tom✓ S F rj w 1 e 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 requirement nd that he/she will comply with suc
h procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR