0022 REAR WEST AVENUE - BPA-10-885 t
( 4 .
• 6
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7 h edition OF SALEM
\ Revised January
\ Building Permit Application To Construct, Repair,Renovate Or Demolish a 1, 2008
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit N ber: Date Applied:
Signature:
Building Commissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 hP opnerty Address: 1.2 Assessors Map& Parcel Numbers
Lla Its this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: - 1.4 Property Dimensions'c•"""'"
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.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 if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1. Owner'of Record:
Nam I'n ) �� Address for Service:
y')e �q(1- V�0
Signana Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK''(check all that apply)
New Construction 0 j Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.Q 1 Number of Units Other Q Speci;5:
Brief Description of Proposed Work': -
�r..
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials) 1
1.Building $ i. nuumng Fermn Fee:$ indicate now tee is determined:
❑Standard City/Town Application Fee
❑'Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4..Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ��s7i ..("7.,.ro 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
-5.1 -Licensed-Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL-Holder List CSL Type(see below)
Address Type Description
U Unrestricted(up to 35 u.Ft.
R Restricted 1&2 Dwelling
Signature M masonry
ND
C Resid hil RoofingCovering
Telephone S Re dential Window and Siding
F -ResidentialSolid-Fuel BurningAppliance Installation
IResidential Demolition
5.2 Registered Rome Improvement Contractor(HIC)
- HIC Company Name or Registrant Name Registration Number
Address
on Date
Signature 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.
Signature of Owner Date
SECTION 7b::OWNER'OR AUTHORIZED AGENT DECLARATION
TI
/ r / Toe ,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. may,
.V, — 1 / 1 I
Print e
V / V
Signaturc,017 Owner or Authorized Agent Date
(Signed under the pains and penalties of
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I I0.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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 S.U.E.Nf
PUBLIC PROPERTY
DEPARTMENT
K11alJriY ev.rvv
ww. i]o v.wu�r�nw l+r.rsr•s�riati Nwanoasrrn 01 f'0
TiL 9'f•7J19S•S • F.ut 9'L7J69a�e
HOMEOWNER LICLNSE EXEIMMON
Please Print
Date
Job Location
Home Owner Address
Home Owner Telephone
Present Mailing Address
The current exemption of"Homeowners"was extended to include ownw-occupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
hire who does not possess a hcenss4 provided that the owner acts as supervisor.
DEFIIe M0N OF HOMEOWNER
Penon(s) who owns a pascal of land on which he/she resides or intends to reside6 on
which there is, or is intended to be, tune 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 Officiak on s 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 equirements
HOMEOWNERS SIGYATL,,
APPROVAL OF BUILDING INSPECTOR
See other side for state code
t ,
CITY OF SALEM
PUBLIC PROPRERTY
4 154" DEPARTMENT
MIt) ,0ly,'I1 I'C1('1N11m...�`t)IMkrT •�.\II11.\t.\ jr ��1iA 1' •14.•
-19
Co struction iiur llDebi ionDIsposaii Affidavit
In accurdafxe with the silth edition of the State building Code, 730 CM section 1
Debris, and the provisions of MGL c 4U,S s4;
is issued with the condition that the debris resulting from
(Wilding Permit ro rl licensed waste disposal facility as defined by MGL c
this work shall be disposed of in p Pe Y
S 130A.
The debris will be transportcd by:
—J�
�+-1 name of hauler)
'I'Ite debris will be disposed of in
(name ul aci Ily .
I;Iddre> 1 u1'I'arllityl
nature nl Iwrmif applicant
ate
• .S�/e%is-loft ✓on/�G-/ �/fin/
s/�3d�Zood Gt/esf ��•
3� o
•ft
a
C'1
�r.
O
35 ESSU RWIMY Of DEEDL SM DISY.DALEM. MAI&
jffh&apu�U� R.a�Yvw _7, t9fil_ w1Mc-�sid:
R.-e_+17. .9 a 179 Rtw r We..14.0. t9 61
R•v+�•�D..es
Lo�not i�quii•�d
ch`o�r-rrTo7�f'o/gym Pb��n9 800i'Z7`
F.ef.✓e�. Fer,�oiwsf•6c•�roc�d 6e� M6 /i.5t6i