17 CAMBRIDGE ST - BUILDING INSPECTION (3) to The Commonwealth of Massachusetts Town of
AZI Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 7'"edition Building Dept
`\(W1 Building Permit Application To C tract. Repair. Renovate Or Demolish a �
One. or Tu' -Funult'Dwelling
This S tion For Official Use Onl
Building Permit Number:h Date Applied:
�� t3 Z�`�
Signature: �
Building ommtssione}/In t f Buildings Date
SECTION 1: SITE INFORMATION
1.1 P operty Address: �) 1.2 Assessors Map& Parcel Numbers
— ' �G.7"ra, ! — Parcel Number
1.1 a Is this an accep' street?yes_ no Map Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(8)
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.40,134) 1.7 Flood Zone Information: 1.g Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal 0 On site disposal system O
Public 0 Private 0 Check if vesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 wrier of R ord: � {, y 1 d �' t
r v
Na (Print) Address for Service::
`I7Y ' 742 ` k0y-5
tgnature Telephone
E TION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction Existing Building O Owner-Occupied Repairs(s) 0 Alteration(s Addition 0
Demolition 0 Accessory Bldg. ❑ Number of Units I Other 13 Specify:
Brief Description of Proposed Work': l.0 2 G t nAltc c 1
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building f 5000 I. Building Permit Fee: f Indicate now fee is determined:
❑Standard City/Town Application Fee
2 Electrical f ❑Total Project Cost'(Item 6)x multiplier x
3 Plumbing f 2. Other Fees: f
4. Mechanical (HVAC) f List:
5 Mechanical (Fire S Total All Fees: S
Su ression
Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: S j D 00 0 Paid in Full 0 Outstanding Balance Due:
r
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
a
' License Number Expiration Date
N,)me of CSL Itylder L CSL A tat Type(ace below)
Address Type I Description
U Unrestricted(up to 35,000 Cu. Ft.)
R Restricted 1&2 FamilyDwe1Gn
Signature M Masonry Only
RC Residential Roofing Covering
Telephone W S Residential Window and Siding
SF Residential Solid Fuel Biuming Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Addmss
Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.f 2SC(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..........O No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
AGENT R CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
a rize to act on my behalf,in all matters
re ' e to work authori a by this building permit application.
C9 i7
Si arum of Owner Date
TION 7b:OiV NEW 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 pains and penalties of peru
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 v&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.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 halfbaths
Type of heating system Number ofdecks/porches
Ts Pe
of cooling system Enclosed Open
1. "Total Pro)ect Square Footage" may he substituted for 'Total Pro)cct Cost"
y
CITY OF SALE.Avt
PUBLIC PROPERTY
DEPARTMENT
u�oriarr^•�•••w
Vnroa i]a Wwurw-ron s7.ssr•spur x,.a�otissrn Orf'0
TEL•..S-104S"•F.%X 978-740.7W
HOMEOWNER LICENSE EXENMION
Please Ftlrat
Date
Job Locadca
Home Owner Address 7"- 6- 0 d u
Home Owner Telephone—� P3 — - k o X3
Present Mailing Addrw i� ra�
The current exemption of"Homeowners"was extended to include owns-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 as supervisor.
DEFINMON 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedureand uirements.
HOMEOWNERS SIGNATL7'� I
APPROVAL OF BUILDING LYSPECTOR
See other side for state code