B-19-1049 - 0123 BAY VIEW AVENUE - Building Permit J
The Commonwealth of Massachusetts t= j f
1. ? Board of Building Regulations and Standards a`�1'EC�'� ��� FOR
' Massachusetts State Building Code,780 CMR i 1-69E LITY
�TgE
• ® Building Permit Application To Construct,Repair,Renovate&bg%1l 4a Revised Mar 2011
One-or Two-Family Dwelling `f 30
r This Section For Official Use Only
Building Permit Number: Date lied:
I
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 ProperFty AJd� 1.2 Assessors Map&Parcel Numbers
L l 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 ft) Frontage.(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
rJ)wner
pply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
fRecord• "��/1.��-dam T��Li�Y'
Name(Print) City,State,ZIP /`--
1-�3 l u/�v� .-ate 13 d
No.and StF6et Telephone Email Address
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 2:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials y
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) $ Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ���p �� 13 Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder,
i List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to'35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
H
HIC Company Name or HIC Registrant Name IC Registration Number Expiration Date
No.and Street Email address
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 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. a
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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this applicatio is true and accurate to the best of my knowledge and understanding.
n wner's or A Ez Ag ame(Electronic Signature) Date
NOTES:
1. An Owner wh tains 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 can be found at
www.mass. ovg /oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
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"maybe substituted for"Total Project Cost"
CITY OF SALEA MASSAC 3USE'I'TS
00 BUILDM DEPARTA ENr
120 WASPIDVGTON STREET,3'm FLOoR
TEL(978)745-9595
KIIOERLEYDRISOOLL FAX(978)740-9846
MAYOR THOMAS ST1>NME
DIRECTOR OF PUBLICPROPERTY/BUILDING ODASOSSIOMR
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE:__
JOB LOCATION
HOME OWNER ADDRESS: —5;0W
PRESENT MAILING ADDRESS: �_3 1iLY111 7z)
The current exemption of"Homeowners"was extended to include owner-occupied dwellings of two(2)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 own 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 access6ry 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 the 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 SIGNATUR
APPROVAL OF BUILDING INSPECTOR /
I ;
1
QTY OF SALE MAS� � SACH[1SE'I'I'S
BUILDING DEPARTWNT
120 WASI-IINGTONSTREET,YDFLOOR
nL(978)745-9595
KIMBERLEYDRISOOLL FAX(978)740-9846
j MAYOR THOMM ST.PIERRE
DIRECTOR OF PUBLICPROPERTY/BUILDING OOMWSSIONER
i
r
Construction Debris Disposal Affidavit
(required for all demolition & renovation work
In accordance with the sixth edition of the State Building Code, 780 CMR,Section 111.5 Debris,
and the provisions of MGL c40, S54; Building Permit# is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licenses
waste deposit facility as defined by MGL c 111,Si50A.
The debris will be transported by:
(name of hauler)
/The debris will be disposed of in:
(name facility)
(address of facility)
)ignatu7re of is t
(today's date)