7 VICTORY RD - BUILDING INSPECTION t
The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 Ch1R, 7'"edition
J Q1�� Building Dept
Building Permit Application To Construct. Repair. Renovate Or Demolish a tit
f� One- or Tiso-Fmnill•Dwelling
This Section For Official Use Only
< Building Permil Number Date Applied:
lI .. C
Signature:
Building Commissioner/Inspec of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address. 2� 1.2 Assessors Map& Parcel Numbers
I.I a Is this an accepted street'.r yes_ no Ma_ D Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq fl) Frontage(fl)
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 Disposal System:
Zone: _ Outside Flood Zone? Municipal disposal y
Public k Private❑ Check if es❑ P On site dis sal system ❑
SECTION 2: PROPERTY OWNERSHIP[
2.1 Xwner[of Record:
Name(Psi Address for Service:
4I-g- S-9 N- s6Y�
Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) ❑ 1 Alteration(s) X Addition ❑
Demolition ❑ 1 Accessory Bldg. O Number of Units_L Other ❑ Specify:
Brief Descnption of P`roposed Work': ec d ki+rt�.
•lees rY�o�e_ ov,'TO �-�l �R• Arcp Aaa a. -��ov�n,\ QcceSS a-o�
*6coj•5t-os \ A- 11 t t'Vi, nett PASS -(--1,rot. k o. 1riYr nr wall
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building E a OOb 1. Building Permit Fee: f Indicate how fee is determined:
2. Electrical E ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
J. Plumbing f wA 2. Other Fees: f�
4. Mechanical (HVAC) S �,�[� List:
9. .4echanical (Fire S N�
Total All Fees: f
Suppression)
Check No. _Check Amount: Cash Amount:
6, Total Project Cost: S a 000 13 Paid in Full 0 Outstanding Balance Due:
r
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
N4mw of CSL- HylJer List CSL Type Uwe below)
Type Description
Address
U Unresincted(up to 33,000 Cu. Ft.)
R Restricted 1&2 Family Dwelling
Signature M %lasonry Only
RC Residential Roofing Covering
Telephone WS Res id ential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D 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.L.C. 152.1 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 .......... O No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, Q �_A P J,,— - -er as Owner of the subject property hereby
authorize ^f'hovvtaS S ltncIcv_i r to act on my behalf,in all matters
relative to rk authorized b building permit application.
��6/09
nature of Owner Date
/� SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
Si1, Ir—o`p,xr-1 A . �ol�cTi e/' ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed 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 W have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS, respectively.
EWhen substantial work is planned, provide the information below:
rs area(Sq. Ft.) (including garage, finished basement/attics. decks or porch)
g area(Sq. Ft.) Habitable room count
f fireplaces _ Number of bedrooms
f bathrooms Number of halfibaths
ating system Number of decks/porches
oling system Enclosed Open
3. "Total Project Square Footage"may he substituted for 'Total Project Cost"
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CITY OF S.ULE.NI
PUBLIC PROPERTY
DEPARTA%IENT
M1 hu1YNw'IL�
HwvOa �'�wASSwrc.-roM SY1FR•SMAK%(A-UAOSLSWM O1970
TIL 978-7354S"• FNL 973.740.9446
HOMEOWNER LICENSE EXEMPTION
Please Print
Date
Job Location T !/ i s c.� 6G d . i S 4 /c.N� ✓"y i
Home Owner Address S a wi e
Home Owner Telephone q 4-T- s9 N- S� 9 9
present Mailing Address -Set ru e—
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 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 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
,APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
r • N It I %I. \I\•.� • .I'+ .
Construction Debris Disposal Allidmit
0CklUired I6r all demo IiIion and rcnu\':niun \vurk)
In accordance w ith the sixth edition of the State Building Code, 7S0 CNIR section I 115
Debris, and the provisions uf'vIGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I1I. S 150A.
The dehris willI be� transportcdby: 1 I/aVla9e Ill" I1 - �ortSW ow�� Olq T)
I name 61hauler) E
he debris will be disposed of in
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