38 WALTER ST - BUILDING INSPECTION t
3
S The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR RECEIVE SALEM
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M Building Permit Application To Construct,Repair,Renova4e 17r'tleit1blis')i a VV
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Applied:
Al,, /
Building Official(Print Naive) Signs -Date
( � I ISECTION 1:SITE INFORMATION
1.1?ro , rddr, ess: t 1.2 Assessors Map&Parcel Numbers
I L l a Is this an accepted street?yes—x'— 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)
From 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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check ifyes❑
SECTION 2: PROPERTY OWNERSHIP'
Owners of Record:JbaW4DIQ70
5tx'tS �R� Ha;er M / 7
Name(Print) City,State,ZIP
3$ " ik 9W 5' to S o1s�8C�5.y�t1.
No.and Street ' Telephone Email Addre
SECTION 3:DESCRIPTI4ON.OF PROPOSED WORK'(check all that apply)
New Construction❑ FExisting Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief�Descripti eA Work:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Offfcial Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application.I=
A Total Project Cost'(Item 6)x multiplier - - x -
3.Plumbing $ 2. OtherFeesi $ -
4.Mechanical (HVAC) $ List:. '
5.Mechanical (Fire $
Su ression Total.All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 0 paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC 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
1,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 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
conta in this a Eition is true and accurate to the best of my knowledge and understanding.
Print Ow erer's or Autl zed 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 not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
wtivw.mass.gov,'oca Information on the Construction Supervisor License can be found at www.mass.<tov/dns
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"
CITY OF SALEM, MASSACHUSETTS
BUILDINGDEPARTMEM
s1. lr" 120 WASHINGTONSTREET,3" FLOOR
TEL. (978)745-9595
KIMBERLEY DRISCOLL FAX(978)740-9846
MAYOR THomm ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONWSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date G/N/I4- \
Job Location sa Wr,
Home Owner Address 3 9 k/u 14�,t./-S�
Present Mailing Address 3 a wo, r/ten sf
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