21 TURNER ST - BUILDING INSPECTION (2) V The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards 410o '•
Massachusetts State Building Code, 780 CMR, T°edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
"ll JJ One- or Tivo-Fmni ),Dx elling
This Section For Official Use Only
Building Permit Num ec Date Applied:
3 � 0
Signature:
Building Commissioner/In ctor of Buildings Date
SECTION 1: SITE INFORMATION
I !Pp �ss: Q( � I 1.2 Assessors Map At Parcel Numbers
i
I.I a Is this an accepted street'?yes_ no Ma_ p Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq it) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.O.L C.40,934) 1.7 Flood Zone Information: 1.8 sewege Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Public❑ Private❑ Check if XesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 wner'of Rgcord� Qll e
Zmc(P Lt Address forService:
�-() —4 I�phone
SECTION J: DESCRIPTION OF PROPOSED W RK^(check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) Alteration(s) [31 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
rief Description of Proposed_Work^: t ✓ `{- C✓1 Vt'IdA -I Ga^
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building Permit Fee: S Indicate how fee is determined:
I. Building S
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
J. Plumbing E 2. Other Fees: S �CJ t
4. Mechanical (HVAC) S List:
5 Mechanical (Fire 5 Total All Fees: b
Suppression)
� Check No. Check Amount: Cash Amount:
6. Total Project Cost: 5 q 150 l�l l 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Constructfon Supervisor(CSL)
License Number ExpjD%elln
Nome of CSL-Helder List CSL Type(see below)
Address T DU Unrestricted u to 35,Signature R Restricted 1&2 Famil
M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registr Name Registration Number
Address
Expiration Date
Signature phone
SECTION 6: WORKE ' 115MPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 25C(6))
Workers Compe on Insurance affidavit must be completed and submitted with this application. Failure to provide
this attida ' 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
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.
..Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
7under
ents and information on the foregoing application are true and accurate, to the best of my knowledge and
� dl
vi
'.i(30 01
wner or Authorized Agent Date T
(Signedhe ains and penalties of fir
FNOTES:
T
Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
t registered in the Home Improvement Contractor(HIC)Program),will�have access to the arbitration
gram or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
struction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I0.R6 and I I0.R5, respectively.
en substantial work is planned, provide the information below:
ors area(Sq. Ft.) (including garage, finished basement/attics, decks or porch)
ving area(Sq. Ft.) Habitable room count
of fireplaces Number of bedrooms
of bathrooms Number of half/baths
heating system Number of decks/porches
cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost'
CITY OF SUX. Ni
PUBLIC PROPERTY
DEPARTMENT
V` 130 wAD"GU w Smear•SAIB{4wQA00.'MM Ot976
7t+1:97L7as-H" • FAX 975-740-9W
HOMEOWNER LICENSE EXEMPTION
Please Print
Date d G 0
Job Location
Home Owner Address <;O "
Home Owner Telephone —4-(Lf45
Preset Mailing Address �LL ✓n g-` 2�—
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 who,does not possess a license.provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Persons) who oats 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 fora 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATL
"���/'
APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SALEM
1 . PUBLIC PROPRERTY
DEPAR"('�fENT
Construction Debris Disposal Affidavit
(required lirr all demolition and renovation work)
In accordance ith (hc sixth edition of the State Building Coda, 780 Cb1R section 1 1 1.5
Debris, and the provisions of'Iv1GL c 40, S 54;
Building Permit It is issued with the condition that the debris resulting from
this work shall he disposed of in a pruperly licensed waste disposal facility as defined by MGL c
l l 1. S 150A.
The debris will be transported by:
I name of hauler)
I he debris will be disposed of in
(namr utfa�ility) -
luddresa „I I�rilitvl -
. gnatwc of ennu applicant
date