21 BECKET ST - BPA-11-735 GARAGE The Commonwealth of Massachusetts CITY
Board of Building Regulations and Standards OF SALEM
Massachusetts State Budding Code, 780 C'MR, 7 edition Revised Jmuutrr
Building Permit Application To Construct, Repair, Renovate or Demolish a l• :00X
One-or Theo-Fu 'I Duel ing
This S F r OBicial-U Onl
Building Permit Number: Date Ap ed:
4,
Signature:
Building Commissioner/Inspecto of it i gs Date
SECT I:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
.ZI 't3e-cKe-1- S� . `fI t3�
Ma Number Parcel Number
I.Ia Is this an accepted street'?yes no P
1.3 Zoning Information: 1.4 Property Dimensions:
S. 02.32.7. t('
Zoning District Imposed Use
Lot Area(sy tt) I'ronmge(it)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Reyuircd
Provided Required Provided Required Provided
I
1.6 Water Supply:(M.G.L c.40,§50) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal III On site disposal system ❑
Public III Private❑ Check if ZesE3
SECTION 2: PROPERTY OWNERSHIP'
?. ;Ites I Owners of Record:
& R ! >3eGke�. St
(2ob4
Name(Print) Address for Service:
4rt 7y5:-;-S-41
Signature . . 'telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alleration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': i x-X
a�
SECTION J: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Ofticial Use Only
Item (Labor and Materials
I. Building S SGOO . I. Building Permit Fee: S Indicate how lee is determined:
O Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S Total All Fees: S
Suppression2
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S $'Cbo4 ❑ Paid in Full ❑Outstanding Balance Due:
L( 0
r f
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
I.icense Number T piratiun Date
Nance of('St..I]older
List CSL 1')pe(see below)
Address I�PC I Description
tl I t!nrestricted no to 35.000 Cu.Ft.
R Restricted 1102 FamilyUwellin
Signature A9 I Masunry Only
RC Resi&2ul RootingCovering
Telephone WS R'.Jomial Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
U Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or I IIC Registrant Name Registration Number
Address
Expiration Date
Signature 'fclephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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.
Signature of Owner Date
SECTION 7b: OWNEW 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
(Signed under the pairs and penalties of •r'u
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 no 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 CMR Regulations 110.R6 and I IO.R5,respectively.
2. When substantial work is planned,provide the information below:
Tula] Moors area(Sq. Ft.) (including garage• finished basement attics,decks or porch)
Gross iiving 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'
CITY OF S.UY—Ni
PUBLIC PROPERTY
DEPARTMENT
nL rs.-u-sere•r•..�c r.tr-,�ssw
HOMEOWNER LICENSd EXEMPTION
Plane Purim
Dale
Job Location 2 I Gcaice� S+.
Home Owner Address z f e e xef s t•.
Hone OwnerTelephoae `lint - 75tf7_ -? 5'YI
Preseet Mailing Address z.t C3ee-k-t st--.
'ne current exemption of"Homeownere 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 ae supervisor.
DF.FINMON OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she sides or intends to reside,on
which there is, or is intended to be,a one or two family dweWng; attached or detached
structures accessory to such use arid/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 wort 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
,.viIf comply with said procedures and mq'u�irements.
HOMEOWNERS SIGNATURE Cal.
APPROVAL OF BUILDING NSPECTOR
See other side for state code
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