7 CHERRY HILL AVE - BUILDING PERMIT APP (002) •r of r _ � Thr Commonwealth Ith Mass achusens
Board ul'BuilJing Regulations and Standards
CITY
Massachusetts State Building Code, 780 CMR, 7'edition OF SALEM
Revised Jumuvr
Iuilding Pe it A lication To Construct, Repair, Renovate Or Demolish a
One-or Twti umily Dwelling
This 5eCtion For Official Use Only
Building Permit Nu Date Applied:
Signature:
--Building Comm d Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Pro dress: �I 1.2 Assessors Map& Parcel Numbers
AL c l
I.1a Is this an accepted str . yes no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use La Area(sit 11) Frontage(it)
1.5 Building Setbacks(it)
From 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 yesO
SECTION2: PROPERTY OWNERSHIP'
2.1 OwnertofR eFun:
L\���( I* �i if 11C�L! P
Name(Print) \�� for Service:
r
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied O Repairs(s) O 1 Alteration(s) ❑ Addition O
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': 54
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OMclal Use Only
Labor and Materials
f. Building S I. Building Permit Fee:s Indicate how fee is determined:
O Standard City/Town Application Fee
?. Electrical f ❑Total Project Coslr(llem 6)x multiplier x
1. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) s List:
S. Mechanical (Fire S
Su «anion Total All Fen:S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S a '' 0 Paid in Full 13 Outstanding Balance Due:
SECTION!: CONSTRUCTION SERVICES -r
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSI.-Ifolder I.isi CSL type!see below)
f cc I Description
Address f U I llmastricicJ(up to 35,000 Cu.Ft.
R I Restricted IA2 Family Dwelling
Signature M M Unl
RC Residential Roulin Coverin
feleplawte WS Residential Window and SiJin
SF Residential Solid Fuel gamin A Rance Imnallaliun
D ResiJemial Demolition
rRegisterede Improvement Contractor(HIC)r 111C Registrant NameRegistration Numlxr
Expiration late
'relephune .
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. IS2. 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
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Vbe �, t as Owner of the subject property hereby
I' th 'zo to act on my behalf,in all matters
relative to work authorized by this building permit application.
Slinsturcorowner Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
1 ,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 Aulhorized Agent late
(signed under the pains and penalties of 'u
NOTES:
I. An Owner who obtains a building permit to Jo his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program).will gg have access to the arbitration
program or guaranty fund under M.G.L.c. IJIA.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations 110.R6 and 110.R5,respectively.
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. Ff.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of healing system Number of decks/porches
Type of cooling system Enclosed Open
). "Total Project Square Footage"maybe substituted for"Total Project Cost"
CITY OF S.XLEM
PUBLIC PROPERTY
DEPARTMENT
��nu� av e�w•n� .
Nwvaa 130WASONGW pSTMW 9IMAK VASA04LQrn019V
TVL 978-715-9S"•F.%x 978.74&9&4
HOMEOWNER LICENSE EXEMPTION
Pin" "I
Dab U
Job [statics
Home Owner Address (/ 1 �0
Home Owner Tel
Present Mailing Address
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
hire who.don not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Persons) 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 detsched.
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
Oflticial. 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 procedures and requirements.
HO.IEOWYERS SIGNATURE
APPROVAL OF BUILDING NSPECTOR
See other side for state code
CITY OF SAL.EM. NWSACHUSETTS
• J BUIIALNG DEPAMIENT
• 120 WASHNGTON STREET, 3" FLOOR
TEL (978) 745-9595
FAX(978) 740-9W
KI�tBF U FY DRISCOLL IHOMASST.PIERRB
MAYOR
DIRECTOR OF PUBLIC PROPERTY/Bt:II.DL�SG COM\fISSIONER
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 11 L5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# is issued with tfie 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:
me of hau er)
The debris will be disposed of in :
(name of facility)
(address of facility)
signature of permit applicant
date
andv�rd,x