45 BARR ST - BPA-2008-818 WOOD STOVE INSERT CITY OF S.ULEM
PUBLIC PROPERTY
DEPARTMENT
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%1AVM 120WAMMGTON S7RWr•SMEK NASSAOR•SEM 01970
71Pi 978-73S-9S"*FAIL 976740.9U6
HOMEOWNER LICENSE EXEMI TION
Please Print
Date a 1 ISI d$--
Job Location q S 1� a Y-r (S)--
Home Owner Address
Home Owner Telephone q -T7- S'q N'5,6 a
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 who.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 dwellin& 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 fort 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 ds the City of Salem
Building Department minimum ' ti es and'requirements and that he/she
will comply with said proced p and q>ri ents.
HOMEOWNERS SIGMA /
APPROVAL OF BUILDING INSPECTOR
See other side for state code
I
The Commonwealth of Massachusetts
;sty Board of Building Regulations and Standards FOR
riff Massachusetts State Building Code. 780 CMR, 7°i edition NIl1NICIP:11.1"fl'
¢tiz;,;r USF:
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Junuul,r
One-or Tiro-Fanuhv Duelling
This5erliiiq For O'ffieial Use Only
Building Permit Nu er: / Date Applied: /
Signature: '�'� .e
Building Conunissioi / Inspector of"Bymi ❑es Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map & Parcel Numbers
(A S 3AM2 S1-
I.la Is this an accepted street'? yes r/no Map Number P;u eel Numhrr
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: /M.G.L a 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 OWNERSHIP'
2.1 Owner'of Record:
. Name(P it) Address for Service:
R3 4? wq- J-61 .
_—tur Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Constru ❑ Existing Building ❑ -Owner-Occupied Repairs(,) ❑ Alterition(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other �pecify: (!Q purl S}evw
BriefDesc`riptio=posed WorkZ: 1-n3 �-- - ;� �►��y ry.�vynr.�-. _�v_•�Xt ) Etwt
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials) Y
I. Building $ L Building Permit Fee: $ —Indicate how fee is determined:
❑Standard City own p [cation Fee
2. Electrical $ ❑Total Project Cost' (Item 6) x multiplier x
3. Plumbing $ -. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire
Su ressiorn $ Total All Fees: $
Check No. Check Amount: Cash Amunt o
(i. Total Project Cost: $ � 0 Paid in Full ❑ Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES c
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Dale
Name of CSL- Mulder List CSL Typc (see below)
iD
Dcscri Lion
Address ` Unrestricted lu to 3i.000 Cu. Fri
Restricted I&I Famil y Dwelling
Signature Masonry Only
Residential Rooting CoverIng
Tclephon, Residential Window .nd Siding
Rcsidcnti:d Solid Furl 13uming :\>>liancr InslallatiimResidential Demolition
5.2 Registered Home Improvement Contractor (t11C)
Registration Number
HIC Company Name or HIC Registrant Name*-
Address ��� Expiration Date
Signature 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
to act on my behalf, in all matters
authorize
relative to work authorized by this building permit application.
Date
Signature of Owner
SECTION 7b: OWNER t OR AUTHORIZED AGENT DECLARATION
I , as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Si ned under the pains and penalties of eriu )
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 and
Construction Supervisor Licensing (CSL)can be found in 780 CM R Regulations I IO.R6 and 110.R5,respectively.
2. When substantial work is planned, provide the information below:
Total floors area(Sq. Ft) (including garage, finished basemenUattics, decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number
halt7ba the
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'