84 ALMEDA ST WEST - BPA-13-857 POOL 00
The Commonwealth of Massachusetts CtCY OF
��• Buard of Building Regulations and Standards S
Massachusetts State Building Code, 780 CM Revisedd Mar R ar
2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling /
this Section For Official se Only
Building Permit Number:;. Dale phedt
2? ffJiSll 3
Building Official(Print Name) 1 Signature I Date
SECTION 1: SITE INFORMATION
1.1 Property Address: L2 Assessors Map& Parcel Numbers
8 I �'L_,I
F1.5
Is this an accepted street?yes � no Map Number Parcel Number
Zoning Information: 1.4 Property Dimensions:
ng District Proposed Use Lot Area(sq ft) Frontage(ft)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2:; PROPERTY OWNERSHIPL
2.1 Owr } R
. o � ordQ OA SQAK2 . �ji 01QT0
Name(Print) City,State,ZIP
g%I Mvivtf dk S7 qrR. 4,N-yzv8. Qhopbo Q ) AIOf.CO,w
PDemol
Telephone Email Address
SECTION 3: DESCRIPTION OF. PROPOSED WORK'(check all that apply),
ction Cl Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
tion of Proposed Work': t w '
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item M
Official Use Only- ,
F3. Plumbin�a
ilding I Building Permit Fee. $ indicate how fee is determined:
❑ Standard:City/town Application Fee
ctrical ❑ Total Pro Cost�,(Item 6)x multiplier x
2. Other Fees: $
chanical (HVAC) List:chanical (Fire TotalAll Fees: .'Sheck No. Check Amount _Cash \mount
Ibtal Prnjuct ('ust' S 0
Qd ( ❑ fiid in Full Cl Outstanding Ikikincc Dua:___
SECTION 5: CONS'TRUCTION SERVICES
5.1 Coostruction Supervisor License(CSI.)
License Number E.epiration Date
Name of CSL I IUlder
List CSL Type(set below)
No. and Street Type - Description
U Unrestricted Duildin s u to 35,000 cu. 11.
_ R Restricted 13c2 Famil Dweiiin
City/rown, State, ZIP (VI blasonr
RC Roofing Covering
WS Window and Siding
SF Solid Fuel &trning Appliances
I Insulation
Teie hone Email address D Demolition
5.2 Registered Home Improvement Contractor(IIIC)
HIC Registration Number Expiration Date
IIIC Company Name or IIIC Registrant Name
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.
Signed Affidavit Attached? Yes .......... 13 No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
Et
WNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
er of the subject property,hereby authorize
my behalf, in all matters relative to work authorized by this building permit application.
er's Name(Electronic Signature) Date
SECTION 7h: OWNER' OR AUTHORIZED AGENT DECLARATION
ng my name below, I hereby attest under the pains and penalties of perjury that all of the information
in this application is true and accurate to the best ofmy knowledge and understandinger's or Authorized.\gcnt's Name(Electronic Signature) ue
NOTES:wner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contactor
(not registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty fund under LM.G.L. c. 142A. Other important information on the IIIC Program can be found at
ww.nl;us.<,uvltca Information on the Construction Supervisor License can be found at wtvw.mas., u�i<IL
2. When substantial work is planned, provide the information below:
Toctl floor area(sq. 11.) _(including garage, finished basement/attics, decks or porch)
(-Irosi living area(sq. tl.) _ habitable room count
Number of tircplacas._—_ — Number of bedrooms —_---_--
Nuntbcrofbathrooms _— Numberofh:dEbaths
--------- --
I'vpe or heating systeln _-. _--- ----- Nnntber ordecks/ porches
I'\peof Cooling .iy;tcnt __—_-- Iinclosetl ___ __-. _. Open _ --
{. l oral Pi'o elr .11 u lr� III:IV illbititutdd rol"' I'w.11 Plojoct Co t"
i
i
CITY OF S.ULE%f
PUBLIC PROPERTY
DEPART.tiIENT
V\{Wilt n.r•.y.
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its,f'}r117Sf! �Y.�i f'<,7i67He
HOMEOWNER LICLNSE EXE.MFTIOV
Plea" Mat
Date /YG? 9t Ld I lob Locadoe 'R Y Afilie do 97 Sc?le m ntf o/5� yO
Home Owner Addreaa Saws
Home Owow Telephone n •'!-t9-y Z y 2,
Pee ant Mailing Address Sa Hn e
Tie current exemption of"Homeowners"was extended to include owsoar-occupied
dwellings of two Units or fees and to allow such homeowners to engage ao individual for
hint who does not posaeae a license provided that the owner acts as supervisor:
DEFINITION OF HOMEOWNER
Perion(s) who owns a pared o[land on which hs✓ahe rtxides or Intaade to reside, on
which then is, or is intended to bo, a one or two &Wly dwelling, attached of detached
strUcttrm acceaory to such use and/or rar'm structures. A parson who constructs more
drag one home in a two year period shall not be considered a homeowner. Such
"Homeowner"shall submit to the Building Oillcial,on a form acceptable to the Building
Official, that helshe 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 bylaws and reguladon&
The undenigned "homeowner'certifies that hdshe undentands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
*ill comply with said procedures and requirements
HOMEOWNERS S(GNATLRE
.APPROVAL OF MLDNG NSPEC7'OR
See other side far state code