7 MANSELL PARKWAY - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 7$0 CMR, T"edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Famih,Duelling
Thil Section For Official Use Only
Building Permit Numt Date Applied: // /�
Signature: hdJ 6// kl�-/
Builth ommission r c of Buildings Date ' —r
SECTION 1: SITE INFORMATION
i.i Pro ert A dr s: 1.2 Assessors Map& Parcel Numbers
W
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: 1
Zoning District Proposed Use Lot Area(sq R) Frontage(B)
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: 1.8 Sewage Disposal System:
Public Private❑ Zone: _ Outside Flood Zone? Municipal On site disposal system ❑
Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.=1?[Record: �
~ 7aC[ou �1Ct S�iCW'(
Narrce{P int) Address for Service:
� � 1-,� �� ��2
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building ( Owner-Occupied I Repairs(s))4J Alteration(s) ❑ Addition ❑
Demolition ❑ J Accessory Btdg. ❑ NumberofUnitsOther ❑ Specify:
rie scription of Proposed Work':t 0
"—
'Z cte
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Offlelal Use Only
Labor and Materials
1. Building S 1. 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 (HVAC) 5 List:
5. Mechanical (Fire S
Suppression) Total All Fees: 8
Check No. _Check Amount: Cash Amount:
6. Total Project Cost: E 3,
Fyrv� 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
LLEicense Number Expiration Date rp
Name of CSL-Hylder L Type(sec below)
Address Description
U Unrestricted(up to 35,000 Cu. Ft.)
Signature R Restricted 1&2 Family Dwelling
M Masonry Only
RCResidential Roofin Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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...........❑
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: OWNERt OR AUTHORIZED AGENT DECLARATION
1, W 1 ArQAA1A0,fF , 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 enalties of r u
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 not 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 110.116 and I IO.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
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.NI
PUBLIC PROPERTY
DEPARTMENT
KJ ast.�,r ,.. ,ti,
Vwroa
130 w.murwTa+sY.Fsr 0 sALM HwssAon'ssns 01970
TIL 978-745-9S"#FAx 978-740.9646
HOMEOWNER LICENSE EXEMPTION
Pleas. Mat
6
Data
Job Location M W tel(.. PKWY
Horne OwnerAddress ses jnE
Home Owner Telephone K L
Present Mailing Address S
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
him who does not possess a license,provided that the owner act@ 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 requirement@.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SALEM
lII PUBLIC PROPRERTY
DEPARTMENT
U +III\i... •:1:.411 r • 1.\I1 \I. %IA"t' _I't
Construction Debris Disposal .affidavit
(requited for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 750 CMR section 1 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit h is issued with the condition that the debris resulting from
this work shall he disposed of in a pruperly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name Lit hauler)
1 he debris will be disposed of in :
(name ul IScility)
luddress ut lacilitvl
slpnatwe of peril app leant
date