0003 CEDARCREST AVE - BPA-15-1274 The Commonwealth of Massachusetts REC9RYE#
Board of Building Regulations and Standards IPlSPE TIOMAWRV1 ES
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Massachusetts State Building Code, 780 CMR Revised.tlar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolis�015 Ov b P
e One-or Avo-Family Dwelling
I ,t This Section For Official Use Only
J Building Permit Number.. Date.Applied'
(( Dailding OlTicial(Print Name) Signature Date
t— SECTION t.SITEINEORINIATION
ll
1.1 Property,�ddress: 11 Assessors Map St Parcel Numbers
3 Celt �'cc2S� S!,Ah 01176
1.In is this an accepted street9 es no Map Number Parcel Number
u Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use
Lot (sq R) Frontage(R)
1.5 Building Setbacks(R)
Front Yard.._ .. .Side Yards Rear Yard
Reyuircd Provided Requited ProJiJed. Regoited Provided
1.6 Nater Supply:(M.G.L c.40,§54) 1.7 Flood Zone Informatlon 1.8 Sewage Disposal System:
- Private O. Zone: _ Outside Flood Zone? Munidpsl O On site disposal system C
Public O
Check if "esCI -
SECTION 2: PROPERTY WNERSHIP),
2.1 Owners f ReeorrO Su Aa Q 9
/C tw}me(Pnrnttyy '- h Shote,ZIP . ..
zj C4c�a�C(e5 � A � -0154-33 5
No.and Sucet - Telephone Email Addicts
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building❑ Owner-Occapied O Repairs(s) ❑ Alterotion(s) l7 Addition O
Demolition O Accessory Bldg.O Number of Univ_ Other O Specify:
Brief Description of Proposed Work°: OO
SECTION 4:ESTIAIATED CONSTRUCTION COSTS -
ME
Offleial Use Only
Item - r iBuilding Building Permit Fee:S Indicate how fee is determined:
Standard Cityfrgwn Application Fee2.Electrical Total ProjectCost'(item 6)x multiplier x
3.Plumbing Qther Fees: $4.\Mechanical (IIVAC) t:
5.\luchanical (Fire S Total All Fees:S
SII rC$SIUII)
,•C`
Check No. Check Amount• Cash remount:
6.Total Project Cost-Ts— I S� 0 Paid in Full 0 outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Cortstructtmr Supervisor License(CSL)
License Number Expiration Date-
Name of CSL Holder List CSL'rype(see below)
No.and Street Type' ,-;, Description
U Unrestricted Duildin tip-to 35.000 cu. It.
R Restricted I&2 Family Dwelling
Oty/rown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Sidinx
SF Solid Fuel Burning Appliances
1 I Insulation
Telephone Email address D I Demolition
5.2 Registered home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
IIIC Company Name or HIC Registrant Name
No.and Street Email address
Ci /Town State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAYIT(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..........O No...........❑
SECTION Tat OWNER AUTHORIZATION TO BE.COMPLETEU WHEN-..
OWNER'S AGENT OR CONTRACTOR APPLIES FON BUILDING PERh11T`
1,as Owner of the subject properly,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) - Date
SECTION 7b:OWNER!OR AUTHORIZED AGENT DECLARATION
By entering my name below,i hereby attest under the pains and penalties of perjury that all of the information
contained in this applic. ' 'sJ a curate to the best of my knowledge and understanding.
/\ Print Owi er' r Authoriz Agent's Nume ecuonic Signature) Date
NOTESt
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 LMJ have access to the arbitration
program or guaranty Fund under M.G.L.c. 142A.Other Important tnfointafion ocheHICYrobram canberto`unda——— — - —
+rww.m;tss.eo+'oca Information on the Construction Supervisor License can be found at ww+v.mass.gov/dos
2. When substantial work is planned,provide the information below:
'rotal floor area(sq. ft.) N (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
'rypeofcoolingsystem Enclosed Open
j. "Total Project Square Footage"may be substituted for"Tut:d Project Cost"
iF
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QTY OF SALEM, MASSACHUSE TTSBUILDING DEPARTMENT120 WASFENGTON STREET,3ftD FLOOR
TEL. (978)745-9595
KIMBERLEYDRISCOLL FAX(978)740-9846
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLICPROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date It//6/15 _
Job Location ga,)l }}
Home Owner Address C"ccc� /},JZ ` lam e A n197-C)
r�
Present Mailing Address
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 that 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 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 understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR
CITY OF SALEg MAssAcHm m
B HIDING DEPAR7)zmr
120 WAS mc=NS7REET,3 0FLOOR
7kL(978)7959595.
FAX(978)740.9846
RIIvJSERLEYDRISaDLL
MAYOR TrKZHlas STAEM
DIRECrCRorPURUCPROPERT AUMDRCCOW& SIOMR
Construction Debris Disposa/Affidavit
(required for all demolition and,renovation work)
in accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, S 54, Building Permit g is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Si ature of applicant
Date