3 WEST CIR - BUILDING INSPECTION 1 sa The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 7'"edition Building Dept
` Building Permit Application To Construct. Repair, Renovate Or Demolish a �
One- or Tito-Fund Dnrlfing
is Section For Official Use Only
Date Applied: O
BwWing Permit Num
Signature: '�—
Bu ding Cornmtssro / spmlor of Buildings Date
SECTION 1: SITE INFORMATION
1.1Pr opMy dd��s � - 1.2 Assessors Map& Parcel Numbers
t
Ma Number Parcel Number
I.I a Is this an accepted street'?yes 1 no p
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Po
Pro sed Use Lot Area(sq fl) Frontage(n)
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.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private ❑ Check if YesE3
SECTION 2: PROPERTY OWNERSHIP' ( n
me(Print) Address for Service: ( � q
OI � � f 1
re
Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) O Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Descn.plio of Proposed Work-:
O&A
1
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Ofllclal Use Only
Item I Labor and Materials
I. Building f 1. Building Permit Fee: f Indicate how fee is determined:
❑Standard City/Town Application Fee
2 Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing f 2. Other Fees: f
s. Mechanical (HVAC) S List:
5 Mechanical (Fire S Total Ali Fees: f
SU ression
Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: fUL s— 0 Paid in Full 0 Outstanding Balance Due:
f '
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
Lacn c Number Expiration Date
N.4me of CSL llylder
a List CSL Type(ace below)
Address T' Description
U Unrestricted f up to 35.000 Cu. Ft.)
Signature R Restricted 1&2 Family Dwellin
M Masonry Only
RC Rcsidcntrul Roofing Coverin
Telephone WS Revdenual Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D I 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.S 25C(6))
Worken 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.
t
Javit Attached? Yes .......... No........... O
7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
AppG ENTORC'ONTRACTOR APPLIES FOR BUILDING PERMIT
` t^ 1'� ` ( as Owner of the subject property hereby
to act on my behalf,in all matters
ork au ed by this building permit application.
wn Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
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 per u
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 W have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. 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.
2. When substamial 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 halfbaths
Type of heating system Number ofdecks/porches
Type of cooling system Enclosed Open
1. "Total Project Square Footage"may he suhstituied for"Total Project Cost"
CITY OF SALE.M
PUBLIC PROPERTY
DEPARTMENT
iufn...�,r e.".•.ti�
Nwro� 130 WA9uNc.•rco STun 9 SALzK N%nAaiLsum ot97o
7 EL VI-745-9S"9 Fnlc 97L740.9616
HOMEOWNER LICENSE EXEMPTION
Please Print 1
Data <Aa� VJ
Job Location �S We S+ CAg"D
Home Owner Address E LAg `-R_C' C S
Home Owner Telephone '1 Rl on-Sl
Present Mailing Address 1n10S 0- o Is)
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.
DEFLNMON OF HONMOWNE t
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 dwellin& 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 requiremen
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SALEM
Iwo PUBLIC. PROPRERTY
DEPARTMENT
Construction Debris Disposal A111da% it
(rctluiwd l'or all demolition :utJ rcnu\soon walk)
in accurnlancc with the sixth edition ul dtc Slate Building Code, 780 CNIR sccuon I I 1 5
Dcbris, and the pro\isiuns of %1GL c 41), S 54:
Building Permit N is issued with the condition that the Dcbris resulting front
this work shall he disposed of in a properly licensed waste disposal facility as defined by mGL c
I 11. S 150A.
The debris will he transportcd by:
1 mime tit hauler)
1 he debris will be disposed of in
(name ,I lain
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