42 BAY VIEW AVE - BPA-14-1949 WOOD STOVE D
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR Revised d/or 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a REGEIY
One-or Two-Family Dwelling
v` This Section For Official Use On1 SER ICES
(� Building Permit Number: Da pplied .1
v ✓Il.�i J . , uti,
Building Official(Print Name).
. Siytalure- ) ))
1 SECTION 1:SITE INFORNIATiorw
1.1 Pro elAddress: 1.2 Assessors Nfap&Parcel Numbers
ILI
1.1a Is this an acce ted street?yes ✓ no Mop Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
"Zoning District Proposed Use Lot Area(sy It) Frontage(Il)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§5d) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yesO
SECTION2: PROPERTY OWNERSHIP'
2 11 Owner of Record: Die 1 V to 010172
�me(Print) City,State,ZIP
y� IA V=cw / �17x 4)9d14 �joon 4fr5 F _C�MCnsfi rre)
No. and Street Telephone Emaild Addresse
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) Cl I Altemtion(s) ❑ Addition ❑
Demolition Cl Accessory Bldg.❑ 1 Number of Units I Other ❑ Specify:
Brief Description of Proposed Work-: ve
�e
t7
SECTION 4: ESTIb1ATED CONSTRUCTION COSTS
Item (Labor
Costs: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee'
2. Electrical S ❑Total Project Costa(Item 6)x multiplier x T
3. Plumbing $ '!�„QtherFees: S ���
•t. Mechanical (FIVAC) S List: (/ U
5. i\Iechanical (Fire S Total All Fees:S
Su ression)
Check No. Check Amount: Cash Amount:
6. Total Project Cust: $ b 1 (/lj 13paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Dale
Name of CSL Holder list CSL Type(see below)
Type `- - Description
No. and Street .
U Unrestricted Buildin s tie to 35,000 cu. It.)
- R Restricted 1&2 Famil Dwellin
Citylrown,Slate,ZIP" Ni Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 I Insulation
Telephone Emil address D I Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
I IIC Company Name or MC Registrant Name
No. and Street Email address
it /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 Ishuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No........... ❑
SECTION 7a.OWNER AUTHORIZATION:TO BE COMPLETED WHEN' "
OWNER'S AGENT OR CONTRACT6RAPP1JES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize -
tg 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 I.G.L.c. 142A. Other important information on the HIC Program can be found at
wvvw.mass. goy y_o Information on the Construction Supervisor License can be found at wvow.mas._ov�'dus
2. When substantial work is planned, provide the information below:
"total tloor area(sq. ft.) `�k _.(including garage, finished basementlattics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number uf-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_
1. "I'otal Project Square Footage" may be substituted for"Fotal Project Cost" -
QTY OF SALEM MASSACHUSETTS
BUILDING DEPARTMENT
120 WASHINGTONSTREET,
Yo FLOOR
TEL.(978) 745-9595
FAX(978) 740-9846
KIMBERLEY DRISCOLL
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMbIISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT: 11 i/
Date 0-- b-01 )h
Job Location
Home Owner Address 5n&Lc—,
Present Mailing Address SR m'e-
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. II
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR