0007 CHARLES STREET - BPA-12-388 The C'onunonweal(h of Massachusetts -- --
i 'i Board of Building Regulations and Standards CITY OF
a i;, Massachusetts State Building Code, 780 CMR SALEM
'L,�., Revised.tlur 201l
Building Permit Application To Construct, Repair. Renovate Or Demolish a
1\C�JJI One-or Two-FamiA'Dwelling
This Section For 'ficial Use only
Building Permit Number: Date Applied:
Building Ol)icial(Print Name) . ignatu [Jute
SECTION I: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Nlap& Parcel Numbers
r'
I.la Is this an accepted street?yes no Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Prmposcd Use Lut Area(sq Il) - Fromage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.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 OWNERSHIP'
2.1 Ownert of Record:
�Auti Moe&ZI A SA e nA MA 01gJo
Nwnc(Print) City.State,ZIP
C- cT 00 -5-Is 'fit u I• MDcAea4 4A
No.and Street Telephone Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction ❑ Existing Building Owner-Occupied Repairs(s) Alleralion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work-: 'CQnovc ,.h
SECTION 4: ESTIiNIATED CONSTRUCTION COSTS
Item Estimated Costs:
ILabor and .\Werials) Official Use Only
I. Building S J�7J 1. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(item 6)x multiplier x _
i. Plumbing S 3 �7 2. Other Fees: S
q. .\leihamical 111\':\CI S List:__
S \ICChanleal (Fire
.tiu i iressionl S 'total :\11 Fees:S
Check No. _('heck:\mount". _ _ Cash Allounr.
t;. Total Project Cost S �� 0 Paid in Full 0 Outstanding Balance Due: -
r! ,
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number -- Expiration Dale
N;uno al'CSI. I folder _---
I.ist C'SL l)pc(see below)
'type Description
I unrestricted(Buildings ti to 35,000 cm 111
_ R Restricted L@2 Family Dwelling
Cityf1'ott n,St:ue.ZIP M Masonry
RC Roolin g Covering
W'S W'indow and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone —[:mail address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
IIIC Registration Number Expiration Dutc
I IIC C'ontpany 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 7s: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 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.
�pv._A It 1 J/?.a 4,)
Print Owner's or ALnhorizcd Agent's Name(FIcctrunic Signautrc) �— ate
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 Hume Improvement Contractor(HIC) Program),will en have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program can be found at
www oce information on the Construction Supervisor License can be found at zn dp,
2. When substantial work is planned,provide the information below;
Total floor area(sq. ft.) _--_1 including garage, finished basement'attics,decks or porch I
Gross living area(sq. ft.) Habitable room count
Number of fireplaces—_-- .—_—_— - __-- Number of bedrooms
Number of bathrooms Number of halfhalns
1. pe of heating S)stem _.__. _ .-._--. -_- — Number of decks, porches
I\pe of cooling Sy stem ... _ Enclosed -Open
I. "Total Project Square Frontage"mm he substituted liar,,rotd Project Cost'
CITY OF S.u.Eaf, AkSSACHUSETTS
9LUALVG DEP-A MLIENT
120 W.UHLYGTON STAE r, }'O FZOOA
itL (978) 745-9595
KIMBERLEV DRLSCOLL FAX(978) 7-9).984d
MAYOR Dt rkouu ST.PM&"
AECTOA OP PI BLIC PROPERTY/3CIIDL%4G CO.\L\lI SSfON EA
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 1 11.5
Debris, and the provisions of MOL a 40, S 54;
Building Permit ti 11, S I SOA.work shall be is issued with the condition that the debris resulting from
1 I I disposed of in a p
1 roperly licensed waste disposal facility as defined by lblOL c
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
. (name or facility)
S�/a W`lr rcL
(�ddrta of Pacihry)
`::R�I'Ma
uyn+nrre ofpermll--- —
Jjte �—
6
CITY OF S.ULE.tit
PUBLIC PROPERTY
DEPARTMENT
�.a..�« 6
VAmae 1311WAs10W"anaar•IMAK VASAOwsara01170
TtL 1'8.745-9s"•FAA 978.1+0.9646
HOMEOWNER LICENSE EXEMPTION
P1eaN Fri�t
Data
Job Location
Home Owner Address '1 lit nt r l--s <,"r
Home Owner Telephone a �r^-I,( S — 2,2 V-?g
Presort Mailing Addtaes "-) r AA ar \-e s S-�-
The current exemption of"Homeowners"was extended to include owneroccupied
dwellings of two Units or Iese and to&How such homeowners to engage an individual for
him who.does not posaae a lieense6 provided that the owner acts as supervisor.
DEFINITION OF HONWOWNER
Persons) who owns a parcel of Ind on which balshe resides or intends to resider on
which there is, or is intended to be,a one or two family dweWn&attached or detached
suucnum 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
PenniL
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
mill comply with said procedures and requirements.
HOMEOWNERS SIGNATURE cw
APPROVAL OF BUILDING INSPECTOR
See other side for state code