20 VISTA AVE - BUILDING INSPECTION The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY'
Massachusetts State Building Code, 730 CMR S M
dMar Revise :Llar2011
Building Permit Application To Construct, Repair, Renovate Or Demo ' a
One-or Two-Family Dwelling
This Sectton For,Offi ' l Use Only.
Building Permit Number:' 'Da Appheti ,.
t 'Y
Building Official(Print Name) . Signature Date
SECTION 1: SITE INFORMATION
k�ooperty�/r��� ��`E 1.2 Assessors Map3c Parcel Numbers
L l a 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(sq ft) Frontage(ft)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.0.E c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2:, PROPERTY OWNERSHIPL 7
2.1 Ownert of Rccord:
Namy,(Print), /��� Ciry,State,ZIP
No.and-SStreetems Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK2'(checkall that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work:
SECTION 4: ESTIMATED CONSTRUCTION COSTS-
Estimated Costs: Official Use Only,.,
Labor and Materials
I. Building $ 1 Building PermitFee S Indicate how fee is determined:
❑ Standud.City/Town Application Fee.
3. Electrical $ ❑Total Prcjeet Costa(Item 6)x multiplier x
3. Plumbin, S 2 Other Fees: S �y
t %lech:mical (lIVAC) S List:
5. \(eehanical (Fire
5
Silt ression) _
Total :\Il Fces: .S
_i�-
n�J� Check No. Check Amount,. Cash Amount:
l'otal Project Cost: S Ut/, 0 Pail in Full ❑ Outstandimr Balance Due:
x ------
V I
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number &epiration Dute
Name of CSL I[older
List CSL Type(see below)
No. and Street Type - Description
U Unrestricted(Buildings up to 35,000 cu. tt.
R Restricted 1k2 Family Dwelling
Cityrrown, State, ZIP %A Nlasonr
RC Roofing Covering
1vS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
FI[C Registration Number Expiration Date
I IIC Company Name or FIIC 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
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.
Print Owner's Name(Electronic Signature) Date
SECTION 7h: OWNEW 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 this applicati ue and accurate to the best of my knowledge and understanding.
Print Ow 5 or Authorized�s Name(Eltt onic Signature) Date
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 Haute Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty find under M.G.L. c. 142A. Other important information on the HIC Program can be found at
�tww.mass.<.uvioca Information on the Construction Supervisor License can be found at%vww.rnass,gL) ^ L
2. When substantial work is planned,provide the information below:
Total tloor area(sq. ft.) _ (including garage, finished basement/attics,decks or porch)
Gross living area(sq. ft.) _ Flabitable room count
Number of tireplaczs Number of bedrooms _-- -- —_--
Number of bathrooms Number of half/baths __
I cpu of heating iystrm . _ -_ Number o(decks; porches - ---- --
I'ti Foclused _ _ Open
i. "total Project Square rootage" utay be sub;litutcd rot "l'ot.11 Pruj xt Co;t"
CITY OF S.ULE.Nf
PUBLIC PROPERTY
DEPARTMENT
u,oWit
`r""Oe i]0 sou 0a sasesr•114— woA0A=M etf'e
Tea.9"2-745.95"•F.kt 978-746964
HOMEOWNER LICLNSB EXEINMIOiN
Pin" Prime
Date -
lob Location 9 0 V I S T4 r/�1/f S// L Fx .
Home Owner Address
Home Owner Telephone /
Presmt Mailing Address S/,AA E 11.6
The current exemption of"Honsaowners"was extended to include owner-occupied
dwellings of two Units or toss and to allow sock homeowners to engage an individual for
hire who does not possess a "caswt provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Pawn(s) who owns a parcel of land on which hahhs resides or intends to reside.on
which there is, or is intended to bo,a one or two Iltmily 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 OQkia% an a fora acceptable to the Building
Official, that he/she be responsible for all such work performed under the Building
Permit
The undersigned "homeownd'assumes responsibility for compliance with the State
Building Coda and other applicable by-laws and regulation&
The undersigned "homeowner"certifla 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 requirement&
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side far state code
[1
CITY OF SiU ENM L LkssACHUSETTS
BUIL011G DEP.IRT[ENT
120 %VASHCYGTON STREET, 3" FLOOR
\\ TEL (978) 745-9595
1Q.%L3ER1 BY DRISCOLL F-MX(978) 740-9846
��L4YOR T110.%W ST.PIE uts
DIRECTOR OF PUBLIC PROPERTY/BL:U oN'G CO-"WIS5IO;IER
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 11 L5
Dcbris, and the provisions of tb1GL c 40, S 54;
Building Permit /# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal racility as defined by IVSGL c
l 11, S 150A.
The debris will be transported by;
(name of hauler)
The debris will be disposed of in
(name of facility) _
— _(address of taaility)
signature of omit applicant
date
f i
t
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