B-19-984 - 0132 BRIDGE STREET - Building Permit The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
Massachusetts State Building Code, 780 CMR MUNICIPALITY
USE
Luildm
uilding Permit Application To Construct,Repair,Renovate Oi Demolish a Revised Mar 2011
One-or Two Family Dwelling
This.Section For Official Use Only
it Number Date Applied:
to s.pngcial(Print Name) �gnature Date
SECTION 1:SITE INFORMATION
1.1�iyrty Address: 1.2 Assessors Map&Parcel Numbers
2. - sr
1.1a Is this an accepted street9 yes no Map Number Parcel Number
1.3 Zoning Information: 1A Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) ? .
1.5 Building Setbacks(ft)
Front Yard Side Yards sWV,.
Rear Yard
Required Provided Required Provided Required Proviftl
�.
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Infoimation: 1.9 Sewage Disposal System:
Zone: Outside Flood Zone?
Public Private O —
Check if yes Municipal 0 On site disposal system
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
I'IIcA.'ey � 5A4ay BJNS'otJ 5J6 LAC M . /21Iq 19 ?o
Name(Print): City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building❑ Owner-Occupied Erl Repairs(s) Alterations) O 1 Addition 0
Demolition 13 1 Accessory Bldg. O 1 Number of Units Other 0 Specify:
Brief Description of Proposed Worht2: d�
AleAl
w SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use 01d
(Labor and Materials 3'
1.Building $ Z p'(rd 1. Building Permit Fee:$ -Indicate how fee is determined:
2.Electrical $ 0 Standard City/Town Application Fee
0 Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ IC03
5.Mechanical (Fire $
Suppression) ll Fees:$ a.
No. Check Amount:��Cash Amount:
6.Total Project Cost: $ in Full 0 Outstanding Balance Due:
i
`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 uildin to 35 000 cu.ft
R Restricted 1&2 Famil Dwellin
City/Town,State,ZIP _.,_.. ' ''" -`%-::M Masonry , • - , 0
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
r
No.and Street Email address
s
City/Town,City/Town,State,ZIP Tel hone
i
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.
Signed Affidavit Attached? Yes..........❑ No...........O
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 r
io'act on my,belialf,'in all inatters relative to`worl authorized by,,this budding permit application: >`
c ,
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
r
By eritering.my name below.I hereby.'attest.under the pains.and penaltieswofperjury that all of the information
, contained in this application is true and accurate to.the best ofmy knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
l. 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.masLgov/oca Information on the Construction Supervisor License can be found at www.mass. ov/d s
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 cooling of coolin s stem Enclosed Open
3. "Total Project Square Footage'maybe substituted for"Total Project Cost"
CITY OF S
ALEM, MA.SSACHCJSE TTS
BUILDING DEPARTAMNT
- 120 WASI�NGTONSTREET,31DFLOOR
AL.(978)745-9595
KMERLEYDRISOOLL FAX(978)740-9846
MAYOR THOMM ST.PIERRE
DIRECTOR OF PUBLICPROPERTY/BUILDING GONWSSIONER
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)
C4*, w�
F (address of facility)
4ignature of plicant
(today's date)
CITY OF SALEA MASSACHUSE'I'I'S
} ~, BUILDING DEPARTA ENT
120 WASHINGTON STREET,3r`D FLOOR
TEL(978)745-9595
KIMBERLEYDRISODLL FAX(978)740-9846
MAYOR 'Ijiows STj)ERRE
DIRECTOR OF PL1B1ICPROPERTY/BUIIAING 00MfiSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE: / 9
JOB LOCATION c Z C i9. S'l'
HOME OWNER ADDRESS:_
PRESENT MAILING ADDRESS:__ l 2- r CYO S I
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 SIGNATURE
APPROVAL OF BUILDING INSPECTOR co�