20 GREEN ST - BUILDING INSPECTION $22.� cv-
Phe Commonwealth of Nlassachusetts CITY OF
Board of Building Regulations and Stand r `I:o`p SALEM
Massachusetts State Building Cod�iSFt IiIR' " $E �ip� ReviseJ,Nur101!
Building Permit Application To Construct, Repair, Renovate Or Demoolissh 2
One-or Avo-Family DwelIjJnV -An
This Section For Official U e nl
Building Permit Number: teApplied
-Building 011icial(Print Name) Signoturo '. Date
(1 SECTION 1.SITE INFORMATION`
11` ' L1 Pxoperjy Add v: 1.2 Assessors Alap&Parcel Numbers
10 [.lots this an accepted street?yes no &top Number Parcel Number
i1.) Zoning Information: 1.4 Properly Dimensions.
Zoning District P.niposed Use _ Lot Area(sq R) - Frontage(R)
1.5 Building Setbacks(R)
- Front Yard Side Yards Rear Yard
Requbcd Provided - Required Provided. Requited Provided
1.6 Water Supply:(M.G.L C.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone., _ Outside Flood Zone? Municipal O On site disposal system O -
Public Private O. Check if.eso
SECnONI: PROPE1tTY,OWNER$HIP4
2.�11n1 Owner of Record: � ,�,il� 019-70
(Pring _ _ - City,-state,ZIP
No.and Strcct Z O Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK:(check all that apply)
New Construction O 1 Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) O Alterstion(s) O Addition O
Demolition O Accessory Bldg.0 . Number of Units_ Other O Specify:
Brief Description of Propos�j Work':
\ SECTION 4:ESTIMATED CONSTRUCTION COSTS
F4.
Estimated Costs: Official Use Only
Labor and Materials
uilding S 1. Building Permit Fee:S Indicate how fee is determined:
0 Standard CilyNown Application Fee
lectrical S O Total Project Cost?(item 6)x multiplier x
umbing S 2�Qther Fees: S
cchanic d (FIVAC) S List:
5.Mechanical (Fire 'total All Fees:S
Su ressiun)
Check No. CheckAmount: Cash Amount:
6.Total Project Cost: S ❑Paid in Full 0 Outstanding Balance Due:
M>att.-cT;) 1-0 IA(' y
�u
SECTION 5: CONSTRUCTION SERVICES ti
5.1 Cunstruction Supervisor License(CSL)
License Number Expiration Date
Namc of CSL[folder List CSL Type(see below)
No.and Street Type. Description .
U Unrestricted(Buildings000 cu. fl.
R Restricted 1&2 FamilyDwellin
City/rown,State,ZIP M Masonry
RC Rooling Covering
WS Window and Sidinit
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
HIC Company Name or HIC Registrant Name
No.and Street - Email address
Cityrrown,State ZIP Telephone
SECTION 6:WORKERS'CONIPENSATION INSURANCE AFFIDAVIT(M G,[ 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 Isivance of the building permit.
Signed Affidavit Attached? Yes ..........o No...........O
SECTION 7a;OWNER AUTHORI2ATION,TO BE COMPLETED,�VHEN'
OWNER'S AGENT OR CONTRACTOR APPLIES BUILDING.PERMIT
1,as Owner of the subject property,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 application is true and accurate to the best of my knowledge and understanding.
Pri t Owner's or Authorized Agent's Name(Electronic Signature) to
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.lnyroyemenl Contractor(NIC)Program);will 1W have access to the arbitration
program or guaranty fund under M.G.L.c. F42A.Othcr tmportanitnforma ton on the HICYrogram can beloimd-at
www.mass.eov;'oca Information on the Construction Supervisor License can be found at AAAA ag&gytdns
2. When substantial work is planned,provide the information below:
'total floor area(sq. R.) (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 healing system Number of decks/porches
Type ofcoolingsystem Enclosed Open
). "Total Project Square Footage'may be substituted 1'or"'total Project Cost"
IX QTY OF SALEM, MASSACHUSETTS
IX
M.
BUILDING DEPARTMENT
int it M. 120WASHiNGTONSTREET,3"D FLOOR
TEL. (978) 745-9595
FAX(978)740-9846
KIMBERLEY DRISOOLL
MAYOR THomAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMIYBSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date
Job Location
Home Owner Address— ,(�Lr#,
Present Mailing Address )w Gg�aN S' &,01
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 SIGNATUREQ�� ,G!/
APPROVAL OF BUILDING INSPECTOR