58 TREMONT ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7"edition
Building
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Tisa-Familr Duelling
This Section For Official Use Only
Building Permit Number. / Date Applied:
Signature: "'am-"' _ ._ rte.(V v
Building Commissioner)Inspector of Buildings Date
SECTION 1: SITE INFORMATION
i Pro erty Address: 1.2 Assessors Map& Parcel Numbers
� r�—.410P-T�
I.I 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 R) 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:
Public❑ Private ❑ Zone: _ Outside Flood Zone?
Check if es[3 Municipal O On site disposal system ❑
j SECTION 2: PROPERTY OWNERSHIP'
j 2.1 Owner of Record:
�Oh x. r bpa rs ea:*44 FI
Name(Print) If Address for
c
orr Service:
e
ature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.O Number of Units Other ❑ Specify:
Brief Description of Proposed WorkZ:
7— P �('Lirc_rl
! SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building S o 0 1. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
O Total Project Cosr'(Item 6)x multiplier x
3. Plumbing 5 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S
Su ression Total All Fees: 5
Check No._Check Amount: Cash Amount:
6. Total Project Cost: E 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
• License Number Expiration Dale
N�mc of CSL-Helder List CSL Type(see below)
Address ' T Descri lion
U Unrestricted u to 15,000 Cu. FL)
Signature R Restricted 1&2 FamilyDwelling
M Mason Only
RC Rcsidenlial Roofing Covering
Telephone WS Residential Window and Sidin
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:OWNEW OR AUTHORIZED AGENT DECLARATION
FtSixned
,asOwner or Authorized Agent hereby declare
statements and information on the for oing application are true and accurate,to the best of my knowledge and
me
of Owner or Authorized Agent Date
nder the pains and penalties of per u
NOTES:
1. 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 nor 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 10.1116 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 livit area(Sq. Ft.) Habitable room count
Number of(replaces Number of bedrooms
Number of bathrooms Number of halPbaths
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.EM
PUBLIC PROPERTY
DEPARTMENT
K11 � r n�wvv
MAYA
I10 w.mw,c,-ra,Sy7Fy7 0 a,^WAssAoa'se'ns 01970
i419'67JS-7S" 9 FAX 9711.74&9&4
HOMEOWNER LICENSE EXEIMMON
Plow Print
Date
Job Location
Horne Owner Address 712,e�fiV O t/7-
Home Owner Telephone
Present Mailing Address C a F
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 structure& 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 requirements.
HOMEOWNERS SIGNATU'REL(��Z��I��A
APPROVAL OF BUILDING INSPECTOR
See other side for state code