2 BORDER ST - BUILDING INSPECTION (2) C
The Commonwealth of Massachusetts I Board of Building Regulations and Standards CITY OFSALEM
Massachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Family Dwellin
y Tlms S�eti0 For Off >Ise;
Build ng Permit Number D 'e Appit
x.
t e �
Buildmg Offiaal(Pant Name) r^ re � ' ate_„ -
SECTIO_N 1. SIT FORMA
1.1 Property Address: 1.2 Assessors ap& Par umbers
A—Of C1
1.1a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: IA Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks (ft)
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:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑ p
SECTION2; PROP RTVs,6WNER5FiIPj°'
2.1 Owner'of Record:
i�. xvlan eta SIzIPYVI WIIA 6��
Name(Print) City, Stale,ZI /_
nn le
No. and Street Telephone Email Addres
SECT1 ON 3i DESCRIPTION.OE PROPOSED Vl QRKZ(check all thatapply)
New Construction❑ Existing Building EllOwner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work:
M_ ..: SECTION•4: ESTIMATED.LONSTRUCTION COSTS ,�> `
Item Estimated Costs: s --Official-IIse, n '
Labor and Materials
1. Building $ 1 Buildmg Permit.Fee $ a ' Indicate how fee is determined;
O Standar& City/Town Application Fee ,
2. Electrical $ ❑,Total Project Cost (Item 6)xmultiplier - x
3. Plumbing $ 2 Other Fees
4. Mechanical (HVAC) $ List Bsl l
5. Mechanical (Fire $ Total All Fees $
Suppression) ",Cheek'No Check Amount Cash Amount
6. Total Project Cost: $ L200 p Paid in,Futl 0 Oufstanding Balance`DnP
=-Holder
ECTION 5: CONSTRUCTION SERVICES '
nse(CS
License Number Expiration Date
List CSL Type(see below)
. tType act r * Description
U Unrestricted(Buildings up to 35,000 cu. ft.
R Restricted 1&2 Family Dwelling
City/Town, State,ZIP M Mason
ry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration-Number Expiration Date
HIC Company Name or HIC Registrant Name
No. and Street
Email address
City/Town, State,ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G3L. 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',OWNERAUTHORIZATION 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: OWNER' 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
www.tnass <>ov%oca Information on the Construction Supervisor License can be found at www.rnq,s eov4lns
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 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"
i
CITY OF S.U.E.tiI
PUBLIC PROPERTY
DEPARTMENT
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HOMEOWNER LICENSE EXE.NMION
Ptew lrtst
Date to R i d�
Job Location ShPt4 b,
Homo Owner Address; ex- I�CN .
Home Owe Telephoto G Kt -14 5 - 344�
Present Mailing Address ,o epardaf 51 Cti taut t YVl l� 6 tq 4e
The current exemption of"Homeowner"was extended to include ownw-occupied
dwellings of two Units or Lean and to allows Such homeowners to engage an individual for
him who.doer not possess a license`provided that the owner acts as suparvisar.
DEFENMONOf HOMEOWNER
Person(a) who owns a pastel of land on which WAS resider or Intstrds to reside, on
which then h6 or is intended to be4 a and or two family dweWng, attached or detached
structures accessary to.such use and/or rum strueturm A person who couatructs more
than one home in a two year period shad not be considered a homeowner. Such
"homeownta 'shall submit to the Building OQleial, on a form acceptable to the Building
OiNciai, that he/she be responsible for all.Such work performed under the Building
PamiL
The undersigned "homeowner"autunds responsibility for compliance with the State
Building Code and other applicable by64aws and retuladona.
The undersigned "homeowner"certifies that he/she undmtand@ the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
.vill comply with said procedures and requirements.
HOMEOWNERS SIGNATLRB
APPROVAL OF 3UILD .NG OiSPECTOR
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