0006 WYMAN TER - BPA 11-293 INGROUND POOL The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
y ) Massachusetts State Building Code, 780 CMR, T"edition OF SALEM
Revised Juntairy
Building Permit Application To n ruct, Repair, Renovate Or Demolish a /. 2MAY
One-or wo- milt/Dwelling
Thii sectioriFor0.16ciai uvAjAnty
1.
Building Permit N mber: D to ied:Signature: U 4 .0 ( /o
Building Cummissione specter of q
w Dye
SECTI N 1:SITE INFORMATION
1 Pro iplerty Address: 1.2 Assessors Map& Parcel Numbers
I.I a Is this an accepted strect9 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 III)
Front Yard Side Yards Rear Yard
Requited Provided Requited Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewnge Dbposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check if yesI3 Municipal On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownert of Record:
DiF,9R
Name(Print) Address for Service:
I7d 74/1/,9.377• c€cc S08. 7Z6 - ro3'7
Signature - Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check aU that apply)
New Construction❑ Existing Building❑ Owner-Occupied D Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ AccessorvRldg.D Number ofUnib_ Other ❑ Specify:
Brief Description of Proposed Work': Dll=_'T,+N�(w'2, -
tr C C o
44
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Omelet Use Only
Labor and Materials y
1. Building 1'v^•F S 3 st73, ""- 1. Building Permit Fee:S Indicate how fee is determined:
�. Electrical $ uo ❑Standard Cilyfrown Application Fee
f �' D Total Project Cost'(Item 6)x multiplier x
J. Plu Is ng TAo`gvv"'i� S 6-00a, 2. 01her Fees: S
4. Mechanical.(S 42t Ft S le> pjJd . List:
5. Mcchanical (Fire S
So ression Total All Fees:S
Check No._Check Amount: Cash Amount:
. Total Project Cost: S %Sty ❑paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
L iccnw Number It.apinhun lyatc
Name of CSI.- Ilolder List CSL type Isee below)
f Descri ion
.Address U llnmiricted u to 35,000 Co.Ft.
R Restricted IR2 FamilyDwelling
Signature M M• 11n1 71
RC Resi lmlial Roulin C'overin
felephrme INS Residential Window and SiJin
SF Residential Solid Fuel gamin Appliance anstallaliun
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or HIC Registrant Name Registration Number
Address Expiration Due
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. ISL f 2SC(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? Yea ..........O No...........O
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.
Si ure of owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1 ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are We and accurate,to the best of my knowledge and
behalf.
Print Name n 2 Y.
2
0
/6•
Signal of a or Authorized Agent Dale
Si on
the aina and nalties of 'u
NOTES:
I. An Owner who obtains a building permit to Jo his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor I HIC)Program),will gg 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 7110 CMR Regulations 110.116 and 110.R5, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.) (including garage, finished basement/anics,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
). "Total Project Square Footage"maybe substituted I'or'Total Project Cost"
CITY OF SALF.M
PUBLIC PROPERTY
DEPARTMENT
Llfall�r.uwvv.
Vwroe t3Dw�wu+s. tnaer 3�i+t Vwa�oRssmON'0
ru.V&745-9s"• K%x.9's•74&9s46
HOMEOWNER LICLNSE EXEIMMON
Please Ftrint
Job Location �r�---
Home Owner Address Kg ,4S4 � -V --
Home Owner Telephone 9 7 'Wt1 < 6?3 ? c4Zu 43- SeIQ 7 0-'e • ro s?
Presme Mailing Address 4? w� i t
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or lean and to allow such homeowners to engage an individual for
hire who,does not possess a license.provided that the owner seta as supervisor.
DEFINMON OF HOMEOWNER
Person(s) who owns a parcel of land on which ho/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 O®ci4 on a form acceptable to the Building
Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeownee assume@ 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 p ad ura and requirements and that he/she
will comply with said procedures and requir ents.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDENG CISPECTOR
See other side for state code
l
135
r � �