B-19-1248 - 0005 BOTTS COURT - Building Permiti
.r
The Commonwealth of Massachusetts -
; l/ i CITY OF
Board of Building Regulations and Standards . vl S- 4 - EM
Massachusetts State Building Code,780 CMR - "
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate.iO
jPNplis8 a .
One-or Two-Family Dwelling ;
This Section For Official Use Only
Building Permit Number: Date Applied:
(60
l3uilding Official(Print Name) S Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map &Parcel Numbers
1 l.la Is this an accepted street?yes ✓ no Map Number Parcel Number
d� 1.3 Zoning Information: 1.4 Property Dimensions:
N 4 1L 0 roq oft
\ Zoning District Prop o' d Use Lot Area(sq ft) Frontage(ft)
�) 1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard �=
Required Provided Required Provided Required Prov ed c"a
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: ''
Zone: _ Outside Flood Z�Dne?
Public Private❑ Check if yesL°I Municipal On site disposal sys�o- 13 .
n
SECTION 2: PROPERTY OWNERSl][IP1 t k.a
2.1 Owner'of Record: ,
Name(Print) City,State,ZIP
rbok 6 -!Of 7 f640 coll 126 wuto' cop-
No.and Street Telephone Email Addres
SECTION 3:DESCRIPTION OF PROPOSED WOR10.(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work2:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ flow 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: 9 /� C�
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount= Cash Amount:
6. Total Project Cost: $ ��000 11 paid in Full 0 Outstanding Balance Due:
r
SECTION 5::CONSTRUCTION.SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
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 Wsomy
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)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town, State,ZIP Telephone
SECTION 6;WORKERS' COMPENSATION INSURANCE AFFIDAVIT(1VLG.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.
Signed Affidavit Attached? Yes ..........R 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: OWNEW 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 application is true and accurate to the best of my knowledge and understanding.
&FW,0t4+.) &c."'ds, 11 a Aof
Print Owner's or Authorized Agent's Name(Electronic Signature) ate
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 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.maaL og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dpss
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 MASSACHUSE Z'I'S
BirIILD=DEPARTMENT
120 WASMq=N STREET,3'0 FLOOR
TEL(978)745-9595
KIIVIBERLEYDRISODLL FAX(978)740-9846
MAYOR THOMAS STYIERRE
DIRECTOR OF PLmucPROPERTY/BumDING OOIu1lv1ISSI0mR
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE:— l 1 /5 )/7,b
i
JOB LocArloN c .
HOMEOWNER ADDRESS: 5- 90#r If00-At r 61?7Z6
PRESENT MAILING ADDRESS: KT CD 01
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 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 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 SIGNATURE
APPROVAL OF BUILDING INSPECTOR/
CITY OF SM ENI, NLASSACHLSETTS
• BU'ILDMIG DEPAR'T111UNT
j 120 WASHINGTON STREET,3w FLOOR
TEL (978)745-9595
FAX(978)740-9846
lQ1iBERLEY DRISCOLL
,)MAYORIOMAs ST.PIERR6
DIRECTOR OF PUBLIC PROPERTY/BEtLDLNG COMMISSIONER
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legiibiv
Manic(BusinLss�Organization/individual): pULt'
Address: . 5 �0#T a Ste. XACI
City/State/Zip: ' e(,6 n , W 00?-0 Phone#:_ �� Zvi—���
0
Are you an employer?Check the appropriate box: Type of project(required):
L❑ 1 am a employer with 4• Q 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).' have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. ❑Remodeling
ship and have no employees These sub-contractors have S. [ Demolition
workingfor me in an capacity. workers'comp.insurance.
Y9. []Building addition
[No workers'comp,insurance 5. [:1We are a corporation and its
,acquired,] officers have exercised their 10.El Electrical repairs or additions
3.U i am a homeowner doing all work right of exemption per MGL I I.El Plumbing repairs or additions
myself.[No workers'comp. C. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees.[No workers' 13.❑Other
comp.insurance required.]
*Any applirua that Checks box Nl must also fill out the section below showing their workers'compensation policy information.
t I lomeowma who submit this affidavit indicating they aft:doing ail work and then hire outside contruwts must submit a new affidavit indicating such.
=Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensatlon insurance for my employees. Below Is the policy and Jab slit
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attaeb a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the ILIA for insurance coverage verification.
I do hereby cert#y u er th aims and penalties of perjury that the information provided above Is true and correct
. ,n.t ire• Date: 451200
Phone#•
01TIcial use only. Do not write in this area,to be completed by city or town oJrciat
City or Town: Permit/I.1cense
Issuing authority(circle one): _
r 1. Board of Health 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other,Contact Person: Phone#:
f
� 36
CITY OF SALEK mmsAaRBE'I'I'S
BumDm DEPARTMENT
120 WASHINGPON STREET,310 FLOOR
TEL(978)745-9595
FAX(978)740.9846
KBOERLEY DRISOOLL
MAYOR THOMAs ST111mRRE
DIRECTOR OF PUBLiCPROPERTY/BumDm 001uIluIISS CMR
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,S150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility).
(address of facility)
SignaCl re f applicant
(today's dat )