1 PIERCE RD - BUILDING INSPECTION The Commonwealth of Massachusetts Town of
O � Board of Building Regulations and Standards
7 ;e Massachusetts State Building Code, 780 CMR, 7"edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
�Jf One-or Ti o-Family Dwelling
This Section For Official Use Only
rBuilding Permit Number: Date Applied: tgnature:
Build'
mi oner/ Spector of Buildings - Date
ECTION 1:SITE INFORMATION
1.1 Pro a Add esti: A 1.2 Assessors Map& Parcel Numbers
/ A LFill r`CMI_
Ma Number Parcel Number
I.I a Is this an accepted street'?yes_ no.
p
1.3 Zoning Information: a 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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 13 On site disposal system ❑
Public[3 Private❑ Check if yesO
SECTION 2: PROPERTY OWNERSHIP' /
2 Owners of Record: /� � / v
Na e( int) � ^ :d,!ess fo �9Signature ephone
SECTION 3: ESCRIPTION OF PROPOSED WORK-(check all that apply)
New Constructionas
Owner-Occupied ❑ Repairs(s) ❑ Alteration(s ❑ Addition ❑
Demolition Number of Units_ Other ❑ Specify:
Brief Desc 'prion of Pro sed
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building S I. Building Permit Fee: E Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S 2Y]j��C��
4. Mechanical (HVAC) S List: c
5. Mechanical (Fire S Total All Fees: 5
Su ression
Check No. _Check Amount: Cash Amount:
6. Total Project Cost: �� VV 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
' license Number Expiration Date
N.4mc ul'CSL- HplJer List CSL Type(see below)
Address Type I Description
U Unrestricted up to 35,000 Cu. Ft.)
Signature R Restricted 1&2 Family Dwnllin
M Masonry Only
RCRcsidcmial Roofin Covering
Telephone WS Residential Window and Siding
SF I 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 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...........❑
SMER
ER AUTHORIZA ION TO BE COMPLETED WHEN
OO CO T R APPLIES FOR BUILDING PERMIT
IN
1, as Owner of the subject property hereby
auto act on my behalf, in all matters
relorize by t is b permit application.
Si Date
SECTION 76:O ERt OR AUTHORIZED AGENT DECLARATION
1, ,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.
Pnnt Name
Signature of Owner or Authorized Agent Date
(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(HIC)Program), will Mol 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 I I0.116 and I I0.115, 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
J. "Total Project Square Footage"may be substituted for 'Total Project Cost"
CITY OF SALE v1
PUBLIC PROPERTY
DEPARTMENT
K110k1riY N".',Y
yAYOs 130 WAOU+C M STXM•SuEK WSLU3�MMM 01970
TEL 978-745.9$"• F.nX.974740.9}10
HOMEOWNER LICENSE EXEIMMON
Please Print /
Date
Job Location ���cct��f� �d�
Home Owner Address
Home Owner Telephone 7 /. 7D 6
Present Mailing Address l�—
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 hdshe 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 rocedures and requi ents and that he/she
will comply with said procedures d requi emen
1
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SALEM
j ''.
(, ,� PUBLIC PROPRERTY
DEPARTMENT
II I 'I'8 'J;. 1;"; . I \C 'i'V V_ 'li Jr,
Construction Debris Disposal .-affidavit
(rcyuiled lilr all del )of itioil and renovation work)
In accordance %kith the sixth edition off lie State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54:
Building Permit # is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I11. S 150A.
The debris will lie transsp/orted by:
(name of haidcr)
I he debris will be disposed of'in
I:uldrev. ..I'I�clluvl
t
a�nutw t It penurt.y,phcam
I�Ir
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