1 MESSERVY ST - BUILDING INSPECTION a
The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
Massachusetts State Building Code,780 CMR, T"edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Fatuity Dwelling
•� This Section For Official Use Only
\\t(1\ Building Permit N mb Date Applied:
Signature:
Buildi Commissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
e5S
1.l a 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(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.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public 13 Private 13 Zone:
if yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 OwnerI'of Record: ly(, V 4 ��
X .r , n 2 �1 -
Name(Prin) . / Address for Service:
Signature- Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ .Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
1. Building S I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Costs(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S Total All Fees: 5
Suppressionj
�(�y Check No._Check Amount: Cash Amount:
6. Total Project Cost: S `CAJ 0 Paid in Full 0 Outstanding Balance Due:
v
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
' L¢croc Number Expiration Date
Name of CSL- Helder Liu CSL Type Isec txlow)
L _
Address Type Description
U Unrestricted(up to 35,000 Cu.Ft.)
Signature R Restricted 1&2 Family Dwelling
M Masonry Only
RCRcsdcntial Roofing Covering
Telephone WS Residenfial 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.
fbehalf
Affidavit Attached? Yes .......... O No...........O
ION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
ER'S A ENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
�^- e_ , as Owner of the subject property hereby
ze to act on my behalf,in all matters
to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
statements and information on the foregoing application are true and accurate,to the best of my knowledge and
e
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of per 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.R6 and 110.115,respectively.
2. When subarstantial work is planned,provide the information below:
Total floors ea(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 S U.EIM
PUBLIC PROPERTY
DEPARTMENT
K111r�=¢y rvw-ry+
VAYM 130w.mun4TONSTREET•SuaaiLWASA0*-= 801970
Ta-VW711-959S 9 FAx 976-744-99N
HOMEOWNER LICENSE E)MMPTION
Please Print
Date `J' Aeb, df
Job Location
Home Owner Address ,+ �-
Home Owner Telephone
Present Mailing Address
The current exemption of"Homeowner"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 then is, or is intended to be,a one or two family dwelling, attached or detached .
structure accessory to such use and/or farm structures. A person who constructs mon
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 requirements.
HOMEOWNERS SIGNATURE `C—
APPROVAL OF BUILDING INSPECTOR
See other side for state code