3 ALLEN ST - BPA-11-319 WOODSTOVE & CHIMNEY INSTALL I The Cummonwcalth of Massachusetts
Board of Building Regulations and Standards CITY
lh 9r Nassachusetts State Building Code, 730 CMR, 7"edition OF SALEM
Revised Jwwary
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1_1008
One-or Two-Fumily Duelling
This,gictionForOfficiai Only
Building Permit N bar: Date pplied:
Signature: Aoz,� /a //-?/w
Building Commissi er/Inspector 'ld ,gs Date
5 ION 1:SITE INFORMATION
LI Prgrrt Address: 1.2 Assessors Map& Parcel Numbers
x , ��,, s:
1.1a Is this an accepted street'?yes_j/ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use [.at Area(sq 11) Frontage(11)
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:
Zone: _ Outside Flood Zone?
Public C3 Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 er'of Record: -
XName(Print)? / Address for Service:
u9�`22f. X73 G/517
Signatu� —� 'rclephone
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': e r ele -rllel
/ j
Cw 4 'til S e?
SECTION 4: E (MATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
I. Building S I. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical S
13 Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier. x
3. Plumbing .S 2. Other Fees: S
4. Mechanical (IIVAC) S List
5. Mechanical (Fire S
Su ression Total All Fees:S
Check No._Check Amount: Cash Amount:_
X 6.Total Project Cost: S,1/00 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Numt er Expiration Date
Name of CSL-I lulder
List CSL Type(sre below)
1\ Description
:\JJnss Il I!nrestrictcd up to 35,000 Cu.Ft.)
It Restricted 1&2 Family Dwellin
Signature M Masonry Onl
RC Residential Routin C'orcrin
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5,2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or FITC Registrant Name Registration Number
Address
Expiration Date
Signature '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 ..........0 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
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I, L as Owner or Authorized Agent hereby declare
that the statemenKand information on Ifie foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Na �-
CG1 --i0
Signature of Owner uthorized Agent Date
(Signed under the pains and penalties ofperjury)
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 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 790 CMR Regulations 110.116 and 110.115,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 he substituted fix"Total Project Cost"
CITY OF SMY—Ni
PUBLIC PROPERTY
DEPARna. LENT
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HOMEOWNER LICLNSB EXEINMIO;N
Pkne "I
DW /�>-ice /D
Job Location 3 5y
HomeO•vnerAddreas 3,41,hfly Sf:
Homeowear?elepbone
Present Mailing Addrees '�3 //,.w Ste.
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of me Units or leas and to allow such homeowners to engage an individual for
hire who does not possess a lic®se,provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to resider on
which than is, or is intended to be,a one or two family dwellins attached or detached
structures accessory to such use and/or farm structures. A person who constructs mon
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
Oilleial, 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 hdshe understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
.vill comply with said proceduresarid requirements.
• HOMEOWNERS SIGNATURE `S
APPROVAL OF BUILDING DiSPECTOR
See other side for state code