8 1-2 WOODSIDE ST - BUILDING INSPECTION r CITY OF S. I.EM
PUBLIC PROPERTY
DEPARTMENT
TU-979•733-9S"*FNc 978-740-9"
HOMEOWNER LICENSE E)MMPTION
Please Print
Date
Job Location
Home Owner Address
Home Owner Telephone \ LA 1
Present Mailing Address c: e—
The current exemption of"Homeowners"was extended to include owneroccupied
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.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside.on
which them is, or is intended to be,a one or two family dwelling, attached or detached
structures accessory to such use and/or fora 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 requirements.
HOMEOWNERS SIGNATURE A >
APPROVAL OF BUILDING INSPECTOR
See other side for state code
The Commonwealth of Massachusetts
FOR
-� Board of Building Regulations and Standards
MUNI('IP.Ai-�T`r
Massachusetts State Building Code, 780 CMR, 7"' edition
USI
Building Permit Application To Construct, Repair, Renovate Or Demolish a Ret twel,lanumi.
One- or Tiro-Family Dire/ling
This Section For Official Use Only
Bu4ding�erm't mber: Date Applied:
Si ma,ut : 2w7w} 5 3
Bd ding Conn ssioner/ Inspector of Buildings Date
SECTION l: SITE INFORMATION
i Pry p Addr s:ert �. Q L P
2 Assessors Mu & Parcel Numbers
fJ MA
�C
I.la Is this an accepted street'? yes no Map Numher Parcel Numher
1.3 Zoning Information: lA Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage (it)
1.5 Building Setbacks (ft) 'Sr7w6 *PO V — i
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
/s-- JO
1.6 Water Supply: (M.G.L a 40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public ❑ Private❑ Check if yes Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Own 'of Record:
Name(Print) Address for Service: -
C
D .
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check 11 that apply)
New Construction ❑ 1 Existing Building ' Owner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. Number of Units_ I Other ❑ Specify:
Brief Description of Pr�)posecl Work': J
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Offici se Only
(Labor and Materials)
1. Building $ L Building Permit Fee: ndicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost' (Item 6) x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire
Suppression)
Total All Fees: ., ZS�•'
B+7
Check No. Check Amount: Cash r\mounr.�_
6. Total Project Cost: $ i U Q Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
if - License Number Expiration Date
Name of CSL- Holder List CSL Type (see below)
Type Description
Address
U Unrestricted(LIP to 35.000 Cu. Ft.)
R Restricted 1&'_' FamilyDwelling
Signature M -.Masonry Only
RC Residential Rooting Covering
Telephone \VS Residential Window and Siding
SF Residential Solid Fuel Burning A i ili:wce Insialhati0m
D 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. § 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.
Signature of Owner Date
pp 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. Sq
Print Name 'Y -
_ Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury)
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 1 IO.R6 and I IO.RS. 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"