15 HARRISON AVE - BUILDING INSPECTION 1
1�
The Commonwealth of Massachusetts e CITY OF
Board of Building Regulations and Standards 2
Massachusetts State Building Code,780 CMR lob �{�ZAA'Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or 7tvo-Family Dwelling
1 Thi;;Seton For C>,�oial Usa
Building Peahtit:Altcr . Dale ed:
. OtSciefiEfritit e) Silluahue
sEcTiONI..$11�$t7 0 7AT[O1W'
1.1 Property-�ct�]d�ress: I/ 1.2 Assessors Map&Parcel Numbers
/�T�-I-F-'�i
L la Is this an accepted street? _yesno_ Map Number Parcel Number
13 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.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone? Municipal p On site sal system E3
Public Privateer — Check ifyeso P disposed
SECTION2i PROP$RTYOWNERS7fl�t
2.1 Owner'of Record: az
rNam'e—(Print) City,Stille,ZIP
No.and Street ,T h Email Address
S$CTION 3:DESCRI PTION OF'PRO
POSED WORK;(ebeck all that apply)
New Construction❑ Existing Building" Owner-Occupied Repairs(s) ❑ I Alteration(s) ❑ Addition 0
Demolition O Accessory Bldg.❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Work": -
3 " o e_)`�-"a r lh /
r[ l_('15FT' ttJ i3"T72o(lM
SECTION 4:ESTIlRSATED CgNSTRUCIION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ 17 Building Permit Fee:$ Indicate how fee is determined
Standard C ily/fown Application Foe
2.Electrical $ O Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. OtacrFees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Toil Ali Fees:$
Su resSion)
Chia No. Meek Amount Cash Amount:
6.Total Project Cost: $ `,j 0 'O U p Paidin pydl p Outstsn ' Balance Ilne:
(�
9 /1 gy �A a .
Si<iCtION 5: CONSTRUCTION S$RVICRS
S.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Tx -- D6scriptim
U I Unrestricted(Buildinas no to 35,000 cu.ft. ..
R I Restricted l&2 I=*DwellM"
City/Town,State,ZIP M I Masonry
RC Roofing Coverm,
WS window and Siding
SF Solid Fuel Burning Appliances
I insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
IBC Company Name or HIC Registrant Name
No.and Street Email address
Ci /town State ZIP Tel hone
SECTION(r WORKERS'CGMPENSATION DMURA,NTCE AFFHIAVIT(ALG.L;c.152.§25C(0)
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...........❑
8BC'T]b6X Tn.-OVMRR AUTHORIZATION TO RIE CO LETED W)II 1N
9WNER'SAGZNT CT¢R.AM
M.yoXHYG
1,as Owner of the subject property,hereby authorize
yX� to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) /
SECTION 96:OWNER'OR AUTHORIZES AGENT MCLARATION
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.
Print Owner's or Authorized Agent's Name(Electronic Signature) Dam
NQU
.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 not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
.nvw.mass.gov!oca Information on the Construction Supervisor License can be found at w nXMgas.eov/dos
2. When substantial work is planned,provide the information below:
Total floor 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"
4 CITY OF SALEM, MASSAMUSE TTS
l 1. Ja BUILDING DEPARTMENT
120 WASHNGTONSTREET,3ftOFLOOR
TEL. (978)745-9595
KIMBERL.EYDRISCOLL FAX(978)740-9846
MAYOR THOMAS ST.PIERRE
DIRECTOR OF PUBLICPROPERTY/BUILDING COMI&SSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT: l/
Date
Job Location
Home Owner Address--I-:5— a Cz / 1)1 7
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
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