14 VISTA AVE - BUILDING INSPECTION ' GK 212R � S�
I Ca5-- 1 �-A
4 The Commonwealth of tMassachusetts RECEQ ER�J� SOF
3 + Board of Building Regulations and Standard SPEC110 SAL Er
1 1 l Massachusetts State Building Code, 730 CM ,¢ev1&,At',r 201
Y�
Building Permit Application To Construct, Repair, Renovate O� ttQdts
One-or Tivo-Family Dwelling
This Section For Official Use Only .
Building Permit Number: Date p tedr f /y
BuilJing Ot7iciul(Pi nt N.une). �signature
SECTION 1:SITE INFORMATION
LI Pr4erty d ress: A 1.2 Assessors INIap& Parcel Numbers
1.In Is this an accepted street?yes__ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sy fl) Frontage(Il)
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 ❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑
SECTION2: PROPERTYOWNERSHIPI'
2.1 Owner of Rc•t /ord: / 'P� en 1 4 co, -l 7 p
e r u� sus,
iT�,ljc(Print)� City,y,State,ZIP i
t� 9287v�3,1�. �tCss� ��
Ate �
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ 1 Owner-Occupied ❑ Repairs(s) ❑ 1 Alterntion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief escripfi n of Proposed Work-:
�\ SECTION 4: ESTIMATED CONSTRUCTION COSTS
Itcm Estimated Costs: Official Use Only
Labor and Materials)
I. Building :S I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical 5 ❑Total Project Cost?(Item 6)x multiplier x
3. Plumbing S P OtherFees: S
4. Mcchanical (HVAC) S List: /
5. Nlechanic:d (Fire S Total All Fees:S
Check No. Check Amount; Cash Amount:
Su ressim,)
`� 6. Tutul Project Cust S 8S�(�^ ❑ Paid in Full ❑Outstanding Balance Due:
/� 5EEV'r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
e7 r License Number Expiration Date
N:une of CSL Holder r j List CSL Type(see below)
No. and Street Type' _ Description
U Unrestricted(Buildings tip-to 35,000 cu. 11.)
R Restricted 1&2 Family Dwelling
Cilyflown,State,ZIP bl Mason
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
S.2 Registered Home Improvement Contractor(HIC)
H►C Registration Number Expiration Date
FIIC Company Name or HIC Registrant Name
No. and Street Email address
City/Town, State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.QL.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 Is§uance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No........... ❑
SECTION 7a:OWNER AUTHORIZATION,TO HE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR HUILDIN61PERMIT
(,ns 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 Name(Electronic Signature) Date
SECTION 7b: OWNERI OR AUTHORIZED AGENT DECLARATION
1 By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
n/ contained in this application is true and accurate to the best of my knowledge and understanding.
A e' D U J
G
Print Owner's ur Authorize Agent's Name(Electronic Signature) Dnte
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 1I.G.L.c. I42A.Other important information on the HIC Program can be found at
www.mas,.covola Information on the Construction Supervisor License can be found at ww+v.mass.uov'das
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"
�` OTY OF SALEK MASSAMUSETTS
BUILDING DEPARTMENT
�,-=��•.�� 120 WASNGTON STREET,3RD FLOOR
��,� 'ILL. (978)745-9595
KIMBERLEY DRISCOLL FAX(978)740-9846
MAYOR THomm STTiERRE
DIRECTOR OF PUBLIC PROPERTYAUILDING MNSUSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, 5 54; Building Permit # is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, 5 150A.
The debris will be transported by:
Lei
(name(name of hauler)
The debris will be disposed of in:
/uon� S,
(name of facility)
(address of facility)
A1iq_ �
Signature of applicant
Date
'1
CITY OF SALEM, MASSACFNSETTS
i n BUILDING DEPARTMENT
nu,�• 120 WASHINGTONSTREET, 3 FLOOR
TEL. (978) 745-9595
FAX (978) 740-9846
KIIvIBERLEY DRIS ou
IMAYOR THONLIkS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMIvUSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE gPRINT: /
Date / � 3 `7 0 -1 ,/� \
Job Location /4 /s� ��i'+f-----/�
Home Owner Address �q I S/dG` !-Y1/_
Present Mailing Address j� V ` SK 4,
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'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR