BAKERS ISLAND - BUILDING INSPECTION (19) The Commonwealth of Massachusetts
, '( A Board of Building Regulations and Standards CITY OF
Massachusetts Slate Building Code, 780 CMR
SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date A 'ed:
Building Official(Print Name) Signature Date
SECTION I:SITE INFORMATION
LI Pr r ddress: 1.2 Assessors Vlap& Parcel Numbers
I.la Is this an accepted street?yes_ no Map Num rer Parcel Number
1.3 Zoning Information: 1.4 Property ProperUty Dimensions:
!oiling District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(ft) -
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(bl.G.l,c. 4Q.,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private Zone: _ Outside Flood Zone?
Check ifyes❑ Municipal❑ On site disposal systern ❑
SECTION 2: PROPERTY OWNERSIIIPt
2.1 Ow 'o Record:
ewe *G'oen /(��zml77, A 7 /Ilf{ �l d't�' 7
Name(Print) City,Statc.ZIP
1ST -oy#!"--z4-i Ao(d�n CcMcrcas ,n
o.and Street l'elophone Eml Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Buildin, Owner-Occupied Repairs(s) ❑ AI[eration(s) ❑ Addition ❑
Demolition ❑ I Accessory Bldg. ❑ Number of Units Other Specily:02e _ v1
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
[tell) Estimated Costs: Official Use Only
Labor and �blaterials)
I. Building $ '^� —� UU I. Building Permit Pee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier_ x _
3. Plumbing $ 2. Other Fees: $
4. Mechanical (IIVAC) $
5. Mechanical (Fire
Su) ression) $ Total All Fees: $----__----
(:'heck No. Check Amount: Cash Amount:
G. Total Project Cost $ r�' /� 00 � �------ --- -----
�S W" ❑ Paid in Full ❑Outstanding Balance Due:
� � l cat
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder 1
List CSL'rypc(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu. ft.)
R Restricted 1&2 Famil Dwelling
City/Town,State,ZIP M Mason
ry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
'role hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or IiIC Registrant Name
No.mid Street
Email address
city/Town, State,ZIP 'fete hone
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, 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) 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
cvww.nrvss.eov/oca Information on the Construction Supervisor License can be found at www.mass.cov/dps
2. When substantial work is planted, provide the information below:
Total floor area(sq. It.) (including garage, finished basement/attics,decks or porch)
Cross living area(sq. R.) _ Habitable room count
Number of fireplaces____ Number of bedrooms _
Number of bathrooms Number of halt/baths _
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"spay be substituted for"'total Project Cost'
a.�
QTY OF SALEM, MASSACHUSETTS
SIIp A BUILDING DEPARTMENT
120 WASHINGTON STREET,3m FLOOR
m� TEL. (978) 745-9595
F
KIMBERLEY DRISCOLL FAX(978) 740-9846
MAYOR THOMAS STYIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and 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, S 54; Building Permit # is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
ell
(name,of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
Date
a
CITY OF SALEM, lMASSACHUSETTS
BUILDING DEPARTMENT
120 WASHINGTON STREET,3MFLOOR
i TEL. (978) 745-9595
F
KIMBERLEY DRISCOLL FAx(978) 740-9846
MAYOR Tt-IomAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date [
Job Location / r /p !�6 /! "11`
Home Owner Address 130, A/zi2 /e LS S / AIIZIN7r''19 7IeI7 1171f 0/0 7
Present Mailing Address ,A
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
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