7 AMANDA WAY - BUILDING INSPECTION (4) � 25
The Commonwealth of Massachusetts
°y,0... Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR RECEIVED SALE Zell
a IN,SP�CTIONAL SER It ES?
Building Permit Application To Construct, Repair, Renova e r Demolish a
One-or Two-Family Dwelling
This Section For Official Use Onl
Building Permit Number: Day AAp'pl_ied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
t Property r ss: 1.2 Assessors Map& Parcel Numbers
/�fll'610,g
I.Ia Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
.o!:ing District Ptopusad Use !,ol Arta(sq fQ Frontage(fit)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes[]
SECTION2: PROPERTY OWNERSHIP!
2.1 Owner of Record:
fnWL-i
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other d Spccily:
Brief Description of Proposed Work'': w alIwn i2gb r +1 c^a Cad
Q. rftnt(ht.-ca Qj 444e e- 1 M-dt I\r eye a 2 it o e�c� cal w II toy oEoM_
c}rj�
I
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ 1� _ ZuYO 1. Building Permit Fee: $ Indicate how tee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List: rb
5. Mechanical (Fire $
Su ression Total All Fees: $
Check No. Check Amount: Cash Amount:
. Total Project Cost: $ l 3 ❑Paid in Full ❑Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
i' "s License Number Expiration Date
Name of CSL.Holder ' ' ' -it I _t442;t
List CSL Type(see below)
No.and Street` :i A Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Mason
ry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulatioa
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Dale
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(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...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,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, 1 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 A horizA Agent's Name(Electronic Signature) Date
NOTES:
I. 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.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
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"
yr.
CITY OF SALzE r ;tiL-1SSACHUSETI'S
BC[LDLNG DEPAMLErT
h, 120 WASHLYGTON STREET, 3' F-LAOIL
T EL (978) 745-9595
KIMBERLEY DRISCOLL F-vx(978) 7-W-9845
NLAYO'a 'n-l0-%vU ST.PIE2A3
DIRECTOR OF PUBLIC PR0PERTY/'a1:=LNG CO-WUSSION ER
Construction Debris Disposal Aftldavit
(required for,all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 C1WR section It 1.5
Debris, and the provisions of NIGL e 40, S 54;
Building Permit k this work shall is issued with the condition that the debris resulting from
l 11, S ISOA. be disposed of in a properly licensed waste disposal facility as defined by yfGL c
The debris will be transported by:
(name of hauler)
The debris wi11 be disposed of in
narnc oC f�cdity)
----(ildress of tircility)
7igrtatur ufpcimit applicant
CITY OF SALEM, MASSACHUSETTS
3 BUILDING DEPARTMENT
120 WASHINGTON STREET,31D FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KIMBERLEY DRISCOLL
MAYOR THomAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONMSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date
Job Location
Home Owner Address 3- h—A—DA t4A-/
Present Mailing Address
The current exemption of"Homeowners' was extended to include owner-occupied dwellings of two
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 owns 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 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 ►r�