13 MEADOW ST - PERMIT APP/VINYL SIDING The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
I Massachusetts State Building Code, 780 CMR, T"edition Building Dept
Building Permit Application To Construct. Repair. Renovate Or Demolish a �
One- or Two-Fmnift,Dwelling
This Section For Official Use Only
Building Permit u er: Date Applied:
Signature: �� --�—
I g Commissioner/Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
13 MP,00cJ ST
MNumber Parcel Number
1.la Is this an accepted street'?yes ✓ noa_ p
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided 2tEEEtEE
1.6 Water Supply: (M.O.L C.40,954) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public� Private 13 Check if yesO
SECTION 2: PROPERTY OWNERSHIP' ✓ J
2.1 Ow { of Reco
( d S fi 6�b
R b?Il���lmm S� g Fe E,v
Namg{Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ 1 Existing Building Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units a Other 13 Specify:
Brief Description of Proposed Work':_ L
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and WalenalsL
I. Building S 61– OOd 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire
Suppression) 5 Total All Fees: S
Check No. _Check Amount: Cash Amount:
6. Total Project Cost: S �,f�6 `�t 400 0 Paid in Full 0 Outstanding Balance Due:
�r
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
LLL—ice—n—hcNumbcr Expvauon Date
N,:)mc of CSL- HplderSL Type(sec below)
sAJJress Desert non
U Unrestricted u to 15,000 Cu. Ft.)
Signature R Restricted 1&2 Family Dwellin
MMason Only
RC Residential Routing Covering
Telephone IF
Residential Window and Siding
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. 152.4 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 ..........17 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 : OWNEW OR AUTHORIZED AGENT DECLARATION
1, ( i �!/)?%�/'^— , 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 ofperjury)
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 110.R5, 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 SALEM
PUBLIC PROPRERTY
DEPARTMENT
III ';-N V9.ISVS 1 \C:'i79 V: ".i J,.
Construction Debris Disposal Affidavit
(required for all demolition and renov:uion work)
In accordance \\ith the sixth edition of the State Building Code, 780 CNIR section 1 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit N is issued with the condition that the debris resultin.- from
this work shrill he disposed of in it properly licensed waste disposal facility as defined by MGL c
I11. S 150A.
The debris will be transported by:
Q . S�wl OYcsa �
(name of hauler)
I he debris will be disposed of in
_Not--tL__Uor-e_ -cl. I h
(name of facility)
laddresa ul Iacililvl �,�- ,,L //��.
,ILllatule Of pcnuit applicant
lat�'
, w
CITY OF SALE of
PUBLIC PROPERTY
DEPARTMENT
K .`..�„tiw•w
Vwroa 130 wASUNGTco SIM=•
suFr.Nwawassrts ot970
71:1.9'.8.715-9S"9 FA)L 97&740.9646
HOMEOWNER LICENSE EXE.MMON
Please Print
Dated a fg—b 9
Job Location I -� YV rm r)e w ST-
Home
THome Owner Address a F-P r� S 7— m ,�t- , /L n
Horne Owner Telephone 9 - - -
Present Mailing Address 9, P-ey S T— (leg ;,-,-, 4A g5i9, =
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 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 "homeownee'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 requireme .
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code