26 BOW ST - BPA-11-759 The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
3" l/ (;�, Massachusetts State Building Code, 780 CMR, 7"'edition OF SALEM
Revised Januarf
Building Permit Application To Construct, Repair, Renovate Or Demolish a /• 1008
One- or Two-Family Dwelling
This Sectipq For Official Ve Only
Building Permit Nu m er: 1 J J,Dzy/A lie
// i
Signature: I -
BuildingCommissioner/hKpector of Buildin Date
SECTION :SITE INFORMATION
1.�roperty�d s: J 1.2 Assessors Map& Parcel Numbers
I I 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(sq It) Frontage(R)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY O RSHHIIP1 c x7
2��ur of Record
Name nt Address f rvice:
S' re
Name
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ rExisting Building❑ Ow - ccupied ❑ I Repairs(s) ❑ Altera[ion(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ umber of Units I Other ❑ Specify:
Brief Description of Proposed Work'-:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
I. Building $ I. Building Permit Fee: $ Indicate how fee is determined:
�. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: S
4. Mechanical (FIVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ DD,dp 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
I.icens-e Number Expiration Date
Name of CSL-I lolder
List CSL 'ype(see below)
'rype Description
Address
lJ Unrestricted(up to 35,000 Cu.Ft.)
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC Residential Rootln;Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I-IIC Company Name or HIC Registrant Name Registration Number
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. 0
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 Own Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
-g- ,as Owner or Authorized Agent hereby declare
that the state nts and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf. F^
Print ame
Sig of Owner or Authorized Agent Date O
(.VkPi5d under the pains and penalties ofperjury)
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. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I I O.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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 halt%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
DBPAM.LENT
w,ouur rnuranL
Name I11 W4908Ud SM&MIT•14AK VAOACKSU T7011'e
rsr.r&74 .95"•VAL f'e 71O9W
HOMEOWNER LICLNSB EXEMMON
PIeaN filet
Dam
Job Lacadm 2 6,
Home Owner Address
' HomeOwnar?eleToleph oae
Pt esant Mauling Adieu Sig!n F
The current namtption of"Homeowners"was extended to include owner-occupied
dwellings of two Units at less and to allow such homeowners to engage on individual for
hire who dodo not possess a Itaeu%provided that the owner acts do supervisor.
DEFINMON OF HOMEOWNER
Pawn(s)who owns a parcel of land on which he/she redden or iniona to redder on
which than is, or is intended to bs6 a one or two dtmily dwelling, attached or detached
structures accessory to such use andlar l4rm stnucturm A pers"who constructs more
than one home in a two yew period shall not be considered a homeowner. Sueb
"homeowner'shall submit to the Building OBlcis& on a form acceptable to the Building
Official, that ho(she be responsible for all such work performed under the Building
Permit
The undersigned"homeownm"assumes responsibility for compliance with the Stan
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner"certifies that hdshe understands the City of Salem
Building Department minimum inspection procedures and requirements and that hdshe
will comply with said procedures and requirements,
HOMEOWNERS SIGNATURE
APPROVAL OF eUILDLYG ECTOR -
See other side for state code
CITY OF SOU EM, .L-1SSACHUSETTS
• BUCIDLNG DEP1R-IMtENT
' 120 WASHLNGTON STREET,3ia FLOOR
T EL (978) 745-9595
FAX(978) 740A8"
KI\tBE UEY DRISCOIl.
MAYOR TAOaL%s ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/BUtLDLYG COMMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
if
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # 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
(name of facility)
(address of facility)
rO1�w C/
signature of permit applicant —
.
date
dn,„ird.k