6 VALE ST - BUILDING INSPECTION Op,
,CIC 30
g� The Commonwealth of Massachusetts i} � ) �
Board of Building Regulations,and Stand"' CT QA�C'5 C ' ITYOF
Massachusetts State Building Code,780 CMR SALEM
l V Relined Mar 2011
Building Permit Application To Construct,Repair,RenoN9tCa(NY'Jbl
emislr9 "Q
One-or Two-Family Dwelling
This,S„etmen For O ioLd iJse t2rtJ '
� Building Par�it Ntaafber , Date Appiled,
i
amig (Print e) Sigaahae '. a
SEC 1ON I:$FTE TION
I.1 P rty Address: 1.2 Assessors Map Bt Parcel Numbers
Ll a is this an accepted street?yes no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq it) Frontage(it)
1.5 Building Setbacks(tt)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Pmvided
i
i
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zcc: ` Outside Flood Zone?Public C3 Private 13 Check ifyos❑ Municipal❑ On site disposal system E3
I 4Namei
rt t Record:
us' o>zd� f ot-(e r c /1'C/`� ON 70
t) // /'�/ yCity,State,ZIP
V'r- 6 JT-t rt' 7d `???-?7Z3 ,S'aba" �DA,-s.tt-Q.&.
No.and Street Telephone Email Address
jDescri *
TION 3:DESCRIPTION OF PR01't)SED WORKr(ebeck aN that apply)
NewExisting Building O Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Accessory Bldg.❑ Number of Hefts Other D Specify:
Briefposed Worm:
SECTION 4:ESTWATEDCONSMUCIION COSTS
item Estimated Costs: Of6eial me Only
(Labor and Materials
1.Building $ i. Building Formii Fres$ Judicate how fee is determined;
2.Electrical $ Cl Standard Cky/rown Application Fee
O Total Project Costs(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: S
4.Mechanical (HVAC) $ List;
5.Mechanical (Fire $
S scion Total All Fees:$
Leek No. Cheek Amount: Cash Amount:
6,To Project Cost: $ PyO¢ ❑Paid in Fail 0 Outstanding Balance Dud:
it
&ECTION 5: CONSTRUCTION SIMVICES
5.1 Construction Supervisor License(CSL)
_ License Number Expiration Date
Name of CSL Holder '•i "'
List CSL Type(see below)
No.and Street Tyge 13eaerlptum
U Unrestricted Wdings up to 35 000 cu.ft.
R Restricted Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Wmdow and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
Ci /fo State ZIP Telephone
SECTION 6:"RX ERS"COMPENSATION RMURANCE.AFFIDAVIT OLG.L c.152.§25C(45))
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...........❑
'Ja:OWNER AUTHORIZATION TO)31E CORIPLETED WHEN
QWNER'S AGE R CO' _ OR AMM FOR „ ING rMM
I,as Owner of the subject properly;hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,l hereby attest under the pains and penalties of perjury that all of the information
co rained in this application is true and accurate to a bestof my knowledge and understanding.
Print Owner's or A thorized Agent's Name(Electro c Signa ate
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 Contactor(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 can be found at
mm maaL&mAoca Information on the Construction Supervisor License can be found at wµx.mass.eov/dos
2. When substantial work is planned,provide the information below: .
Total floor 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"
f al Y OF SALEM, MASSAMEETP.'
BtnDDYGDBrAJMMnrr
' uo W.sumar,'nantS�T,3�73roae
7L"745-9995.
Fiu[
BII�ERiEYDLi 7,149816
A"YCR 71aa�sS7.P
Dmsc7mc+rasuc /sumcmamaasgcem
Construction Debris DisposaiAffrdWit
(required forall demolition and.renovition work)
in accordance with the sbth edition of the State Building Code, 7W MR, Seth 111.5 Debris,
and the provisions of MGL o00,S 54; BuNdhig Permit 8 is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit fadlity as defined by MGL c 111,S 1S6A.
The debris will be transported by.
S .has.
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature o�applicant
Date
All
QTY OF SALEM, MASSAC HUSE ns
BUILDING DEPARTMENT
120 WAsmNGTONSTREET,3"D FLOOR
TEL.(979)745-9595
FAX(978)740-9846
KIMBERLEY DRISCOLL
MAYOR THows STTIERRE
DIRECrmoFP mucpROPERTY/BUILDINGCC)AWSSIQNER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
1 Date ('M
6
Job Location
Home Owner Address
Present Mailing Address
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 that 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 "homeowner"certifies that he/she understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR