13 ROCKDALE AVE - BUILDING INSPECTION The Commonwealth of Massachusetts
t� wnof
Board of Building Regulations and Standards To
a� Massachusetts State Building Code, 780 CMR, T°edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a �
One- or Tuo-Family Duelling
This Section For Official Use Only
Building Permit Number: Date Applied: f
Signature: r "
Building ommissioner/I for of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property A dregs: 1.2 Assessors Map At Parcel Numbers
C _e Atm f
I.I a Is this an accepted street?yes—L/— no_ Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq tt) Frontage(R)
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,l54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑
Public[3 Private[3 Zone:
if yesO
pp SECTION 2: PROPERTY OWNERSHIP' l
.` 'tOCT�.\/er o1Record: 2z-'c L�Ao)e 2 )�
4 Na a Pnn Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied 18( Repairs(s);ET Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units--L— I Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: OMcial Use.Only
Item Labor and Materials
I. Building Permit Fee: f Indicate how fee is determined:
X I. Building S ❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: E
4. Mechanical (HVAC) S List:
5. Mechanical (Fire 5 Total All Fees:E
Suppression)
/� �, � 1 Check No. _Check A ours': Cash Amount.
6. Total Project Cost: S ( U vv 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES ,.
5.1 Licensed Construction Supervisor(CSL)
r
License Number - Expiration Date
N4mc of CSL- Hylder
� List CSL Type Isar below) I
Address NDTResidential
Description
stricted u to 35,000 Cu. Ft.)
Signature icted 1&2 Famd Dwellin
n Onlential Roofin CoverinTelephone ental Solid Fel Bum A liance Installation
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
I. 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: OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declarJand
li,
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
behalf. \
Pri a \
Signatu of Owner or Authorized At Dale
(Signed under the pains and 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 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 I O.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 SALEM
PUBLIC PROPERTY
DEPARTMENT
q1O�!ry D�wvv i
VAVOt
13Ow.lvUlWTOn Sr1FiT•SALEK,ywstA04LWM 019?0
TEL 9711-1459S"• FAX 9711-740.984
HOMEOWNER LICENSE EXEIM"ION
Pies"PPriott� ��q
Date
Job Location
Home Owner Address r-0. p(ct ?o
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 homeowner to engage an individual for
hire who does not possess a licaum;provided that the owner acts as supervisor.
DEFINITION OF H0l1ZOWNEIt
Person(#) 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 requi n ents.
HOMEOWNERS SIGNATUP
APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SALEM
l� * PUBLIC PROPRERTY
�1N lrn
DEPARTMENT
Construction Debris Disposal Allidavit
(required li)r all demolition and renovation work) k;
t
1
In accordance %%till the sixth edition of the State Building Code, 780 C'MR section I 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit if is i55ncd 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 be transported by:
j ( �m�,�i ,nC
nac of haulm)
Ilse debris will be disposed of in
(namr ul facllnv)
laddress ;d facdnvl
lc alt p:nuu applicall
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