84 ALMEDA ST WEST - BPA-13-428 The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards
SALEM
Massachusetts State Building g Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One or Two Family Dwelling
This Section For Official Use Only 7
Budding Permit Number v
Building Official(Print time)
SE"CTIONI 81TE'I, , ORMATION* ,,
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
Ss�f ti-{wiedG SZ G✓eg'F
1.1 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 ft) Frontage(8)
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:
Zone: _ Outside Flood Zone? Municipal El On site disposal system ❑
Public❑ Private❑ Check if yes❑
S CTION'21 P$OPERTVOWNERSmR"P ' _.
2.1 Owner'of Record: SQ�Ba✓1 if a i Q 7 6
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Name(Print) City, State,ZIP
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No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED'WOkK (check all that-apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ I Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work":_ry_C fa / &/Co(l A ".i kr �1LY
SECTION 4: ESTIMATED CONSTRU,.CTION COSTS '
Estimated Costs:
Item Labor and Materials Offioial Use Only
1. Building $ 1 Budding PermiE.Fee $ Indicate how fee is determined:'.
❑ Standard City/Town Application Fee s
2. Electrical $ ❑Total Ero�ecf Co'stt(Item 6)_x multiplter x
3. Plumbing $ 2 Other Fees $ /7� �
4. Mechanical (HVAC) $ Ltst �Z!
5. Mechanical (Fire $ Total All Fees $`
Suppression)
Check No ChEck Amount Cash Amount
6. Total Project Cost: $ El Paid n Full ❑ Outstanding Balance Due
617"v -
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1^'`�
=Holder
SECTIONS: CONSTRUCTIONSERVTCESense(CSL) License Number Expiration Date
List CSL Type(see below)
. pe `Descript%on
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 Bu"AppliancesI Insulation
Tele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration N
HIC Company Name or HIC Registrant Name
No. and Street Email address
City/Town, State, ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE'AFFIDAVIT(M.G.L. c. 152.:§ 25C(9
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''
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 7bi .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 application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Oate
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.rnass.eov/oca Information on the Construction Supervisor License can be found at www.mass.�
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"
CITY OF S.U-F.Nf
PUBLIC PROPERTY
DEPARTMENT
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HOMEOWNER LICE.�1SE EXItM"101V
PIeeN Met
Date
Job t«ados s P /yPkedo S f Ales7'
Home Owner Addreas Oa,,k e
HomeOuoerTelepbom r,jxe ti7-4 •YZZtR7
Present Mfg Addrese Sc( if niedc- S,_ t..csT.
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or(eye and to allow such homeowners to engage an individual rot
bins who does not possess a license provided that the owner acts as supervisor.
DEFWMON OF HOMEOWNER
Person(s) who owns a parcel of land on which hahhe resides or intends to reside, on
which there iy or is intended to bey a one or two family dwelling, attached of detsched
swxnwm accessory to such use and/or rum structures. A person who constructs more
than one home in a two year period shall rot be considered a homeowner. Such
-homeowner"shall submit to the Building OQkial, on a form acceptable to the Building
Official, that hdshe be responsible for all such work performed under the Building
Permit
The undersigned "homeowner''assumes responsibility rot compliance with the State
Building Code and other applicable by-laws and reguladons.
The undersigned "homeowner''certifies that halshe understands the City of Salem
Building Department minimum inspection procedures and requirements and that Wshe
.veil comply with said procedures and requirements.
HOMEOWNERS SIGNAMW
APPROVAL OF BUILDING ftiSPECTOR
See other side far state code