14 GROVE ST - BUILDING INSPECTION i
OX
a The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
OFSALEM
Massachusetts State Building Code, 730 CMR, 7'"edition
Revised Ja n arp
Building Permit Application To Construct, Repai , Renovate Or Demolish a
One-o tro-Funnily Dt /ling
This ction For ficial Use Only
Building Permit Nu beerrr: 1
ate Applied: )
Signature: /�� /��
Building Commissioner/Inspector!!M
Idings Date
1
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
I.1a 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 It) 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❑ Private❑ Check if es❑ Municipal❑ Onsite disposal system 11
SECTION 2: PROPERTY OWNERSHIP'
Owne t of d: R
u e(Pnnt) (l I Ad�s��p'S�t7
ignature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. Number of Units Other 13 Sp if,
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
L Building S I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑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
Suppression) Total All Fees: 5
Check No._Check Amount: Cash Amount:
6.Total Project Cost: Sc3zlxr d D ❑Paid in Full ❑Outstanding Balance Due:
as-D�
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Numher Expiration Date
Name of CSI.-I Iohler
List CSL Type(see below)
1r Description
Address U Unrestricted up to 35,000 Cu.ft.
It Restricted 1&2 Family Dwelling
Signature M Nlasonry Only
RC Residential Roofing C'overin
Telephone WS Residential Window and Sid nit
SF Residential Solid Fuel humin Appliance Installation y.
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) r
1IIC Company Name or FITC Registrant Name Registration Number
Address
Expiration Dam
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(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 .......... ❑ 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.
Signature of Owner Date
SECTION 7b: OWNE t OR AUTHORIZED AGENT DECLARATION
I � ,as Owner or Authorized Agent hereby declare
at 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 Uate
(Signed under the pains and penalties of perjury
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(FIIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A.Other important information on the"IC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations 110.116 and 110.115.respectively.
2. When substantial work is planned,provide the information below:
Total (lours 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 be substituted for"Total Project Cost"
CITY OF SM.E.11
PUBLIC PROPERTY
DEPARTMENT
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HOMEOWNER LICLNSE EXEMPTION
Plew "I
Dam /z-/-J D
Job I ocados I Z-1 6 0 n U I— U
Home Owner Address
Home Owner Telephone - —6
Preamt MWinB Address /,,f G 2 a V 8; F
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 wbo.does not possess a licenses provided that the owner sets as supervisor.
DEFINMON OF HOMEOWNER
Penon(s) who owns s parcel of land on whieh hdd w resides or intends to reside.on
which there is, or is intended to be.a one or two &milt'dwellin& 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 Mist on a form acceptable to the Building
OtfIciaL 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 SIGNAM �
APPROVALOFOUILDING SPECTOR
See other side for state code