27 BECKET ST - BPA-11-917 WINDOW d-,�7 S h
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The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised.t tar 2011
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Building Permit Application To Construct, Repair, Renovate Or et
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: D Applied: /
1
Building Official(Print Name) Signat a Dat
SECTION I: SITE INFORMATION
I�Propert ejSL f_. -lG�n 1.2 Assessors Map& Parcel Numbers
7 ��
I.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area Isq tl) Frontage 111)
1.5 Building Setbacks(it)
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?Check if ycsE3 Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: / C.��L(�.n AIA— /4 7d
.7LGL/7 �eJ'/Plre �p Q
Name(Print) City.Slate,ZIP
a SI • :�/7 y,7?47.5Z
No.and Street 'telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) Alterations) ❑ 1 Addition ❑
Demolition ❑ .Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Propo ed Work-:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building $ nd0 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
3. Plumbing S 2. Other Fees: S
4—Mechanical OfVAC) S List:
5. Mechanical (Fire S
Su m mression) Total All Fees:S
Check No._Check Amount: Cash amount:
G. Total Project Cost: S ❑Paid in Full ❑Outstanding Balance Due: ---
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0
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number P.xpiration Date
Name of C'SL I folder
List CSL T)pe(sec below)
No. and Street Type Description
U I Inrestricted(Buildings u' to 35,000 cu. ft.)
R Restricted 1&2 Fmnil Dwellin
Oily/Fo,vn,Stale.ZIP M Nlason
ry
RC Rooting Covering
W'S Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
'I'cic hone Ismail address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
IIIC Registration Number Expiration Dale
IIIC Company Name or I IIC' Registrant Name
No. and Street
Email address
City/Town, State,ZIP Telephone
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
I, 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 ORAUTHORIZED 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 arAurate to the best of my knowledge and understanding.
I'rin wner'son�ulhorizeJ Agent's Name(IBecuunic:Signature) ate
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
\%.nm>,g,n oc;i Information on the Construction Supervisor License can be found at o%kw.nmsa.^o� dp;
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 Numberofbcdroonts
Number of bathrooms _ Number of half:baths
l' pe of he:uing s)'stent _--- --—_--- dumber of decks, porches __ ----_-
l\pe ol'cooling system.- __—_-_ Enclosed
3. "Fot:d Project Square Footage"may be substituted for"Fatal Project Cost"
CITY OF S,-kL&Ni, ,%WSACHUSETI'S
BLAZING DEPARTMENT
120 W.,k.sHLNGTON STREET, 3i0 FLOOR
TEL (978) 743-959S
FAX(978) 740.9846
Kl.% BE U-EY DRISCOL L
MAYOR Tto.NAs ST.PIERRa
DIRECTOR OF PLOLIC PROPERTY/131.31.13MG 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 l 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit Al is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris
�will be disposed of in
//D.4'A
/L (name of facility)
(address of facility)
signature of permit applicant
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CITY OF S.U.E*vf
PUBLIC PROPERTY
DEPARTONLENT
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HOMEOWNER LICENSS EXEMPTION
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Home Owner Address a 7 �vcc cf
Hums Owner Telepbone /o/ Z •G 6
Pcesmt Mailing Address fb BoX.�9 yr
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units at leas and to allow such homeowners to engage an individual for
hire who does not possess a liece ss4 provided that the owner acts as supervisor.
DEFINITION OF HONZOWNER
Persons)who owns a pssed of Ind on which he/she resides or intends to reside6 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 O®cial,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 bylaws 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
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING PECTOR
See other.side for state code