15 CEDARVIEW ST - BUILDING PERMIT APP (002) ,d9
The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
Massachusetts State ilding Code, 780 CMR, T"edition Building Dept
Building Permit Application To onstruct, Repair, Renovate Or Demolish a
One-or T Fundly Dsrrlling amma
is ction For Official Use Only
Building Permit Numb
Date Applied: (re,'
Signature:
Building Commissio er/ s t of Buildings Date
SECTION I:SITE INFORMATION
X 1.1 Pro,�+erty Address: 1.2 Assessors Map& Parcel Numbers
1 S ["Pilar eJ, S
I.I 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 ft) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.O.L C. 40,§54) 1.7 Flood Zone Information: l.g Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Public❑ Private❑ Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: /1
\...,.. . �1 �... r-F-Y� 1 S l PCQ/acy ie�_0
Name Print) Address for Service:
2 , �� �k—aZc�F
Signature
Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑
XDemolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
IN
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Offlcial Use Only
Item Labor and Materials
I. Building E I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical 5 ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing 5 2. Other Fees: E 2
4. Mechanical (HVAC) 5 List:
5. Mechanical (Fire 5 Total All Fees: E
Su ression
Check No. '34ALCheck Amount: Cash Amount:
x- 6. Total Project Cost: b paid in Full ❑Outstanding Balance Due:
L
SECTION 5: CONSTRUCTION SERVICES .y
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Dale
Ngmc of CSL- Helder
A
List CSL Type(sec below)
Address T Desert tion
U Unrestricted u to 35.000 Cu. Ft.)
Signature R Restricted 1&2 Famil Dwellin
M as
Only
RC Residential Roofing Cove-ring
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Dale
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
1• ,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.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of peru
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 no 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 I I O.R6 and I I O.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
LT
umber of fireplaces Number of bedrooms
umber of bathrooms Number of half/baths
ype of heating system Number of decks/porches
ype of cooling system Enclosed Open
3. 'Total Project Square Footage"may be.substituted for"Total Project Cost"
CITY OF S.U.E.Avf
PUBLIC PROPERTY
DEPARTMENT
K1lOk1lLY�vwn�
yAv'O! 130wADdsomM St9E=9&m.M%L%uAOtisKM 01970
TEL 978-7454S" •F.tx.976.710.9646
HOMEOWNER LICENSE EXEMPTION
Please Print
Date �—6-09
Job Location
Home Owna Address S C�okc�su�eA SuA . 1, Q o �t`t0
Home Owner Telephone Gig- �e e- q Zoe
Present Mailing Address t
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 s 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 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
APPROVAL OF BUILDING INSPECTOR
See other side for state code