3 WEST TER - BUILDING INSPECTION a The Commonwealth of Massachusetts
�\ Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, T°edition OF SALEM
Revised Junrrury
Building Permit Application To Construct, Repair, Renovate Or Demolish a ?omf
One-or Two-Fumi1v Dwelling
This Section For Official Use Only
Building Permit Num r: Date Applied:
Signature:
Building Commissioned lns#fctor of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: I.2 Aasesson Map& Parcel Numbers3 West T 0WIR
I.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 11) Frontage(11)
1.5 Building Setbacks(R)
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?
Public❑ Private O Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 S A s of Record,"aM. Lo u �z 3 war TeKe"
Name(Print) Address for Service.
SAMAAA,w 4t5 . 370 .9o�3y dy ?8/ - ,5Z41TQn/�
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(cbeck all that apply)
New Construction❑ Existing Buildingg Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Pi Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': �P � 2 �i�ir-f A/ ��T
G'Of♦T CGPXiPT @ giMT7?�i/
X SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S Total All Fees:S
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: S ❑Paid in Full ❑Outstanding Balance Due:
r�, l
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL-I folder List CSL Type(see below)
.f Description
Address U Unrestricted(up to 35,000 Cu. Ft.
R Restricted Id2 Family Dwelling
Signature M Masonry Only
RC Residential Routing Covering
fclephone WS Residential Window and Sidin
SF Residential Solid Fuel Buming Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or IIIC Registrant Name Registration Number
Address Expiration Dale
Signuturc Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C. 152.1 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 ..........O No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGGEN,T/OR eACONTRACTOR APPLIES FOR BUILDING PERMIT
1, 5'u DlAI v ,�'I t as Owner of the subject property hereby
authorize p �n� �o ' to act on my behalf, in all matters
relative to work authorized by this building permit application. G/
Sianauurc of Owner Date
SECTION 71b: OWNEW OR AUTHORIZED AGENT DECLARATION
1 7DfJ l V as Owner or Authorized Agent hereby declare
that the statements and information oonn�ihe foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
signature ol'( ner or Authorized Agent Date •G/
Si ed under the ams and penalties of perjury)
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 gol 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 110.116 and I IO.RS, respectively.
? 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.XL.E.Ni
PUBLIC PROPERTY
DEPAM7 PENT
Vwrw 13eWAPYNGT Msprat•smuti%1As%Aoasms or9-o
t4i rG-7454s9s• F.uc 93.74&964
HOMEOWNER LICENSE EXE.IIPTION
Plan "I
Date 5 2 fl
lob Locatim W t3!�,T
Home Owner Address VJ
Home Owner Telephone O• �i
Present Mailing Address
I
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.
DEFINMON OF HOMEOWNER
Person(s)who owns a parcel of land on which heshe 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures uiremrnts
HOMEOWNERS SIGNAT(.'RE
APPROVAL OF BUILDING INSPECTOR
See other side for state code
e '
,S CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
1.11: M111 ' MI+e ,'.11
1 IC%'.%+111\b:e1V jl'Mkl"r 0$•111\1, 1t.\+i.\I 111 4 I
Construction Debris Disposal Affidavit
(required lux all demolition mid renovation work)
In accordance \vith the sixth edition of the State Building Code, 730 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit M is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
llima of hauler)
The debris will be disposed of in :
(lcune u► acillty
taddms of facility)
+Isnalure of permil applicant
J Vs I
date
k Pn•dl.