0006 CHEVAL AVENUE - BPA-10-410 i
� I
The Commonwealth of Massachusetts Town of
�I u+ Board of Budding Regulations and Standards
f1
i V
dM assachuscs State Code. 780CNIR. 7"edition Bud�iW Construct. Repair. Renov
ate Or Demolish a fiber
1 Building Perim Application To C p
U tvo-Funtth'Omelhn
' I ne- or T 8
This Section Far 011ictal Use Onl
BwI ing Permit Number Date Applied:
signature:
Budding C isnoned I ar of Bwldmgs Dsts
SECTION I:SITE INFORMATION
1.1 Property Address: ,7 1.2 Assesson Mop i Parcel Numbers
no --
M Number Parcel Number
I.1 a Is this an uee led street!yes W
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ill Frontage IN
1.! Building Selbocks(R)
Front Yard Side Yards Rear Yard
Requited
Provided Required Provided Required Provided '
1.6 Water Supply:(M.G.L c.40.154) 1.7 Rood Zone Information: 1.8 Stronger Disposal System:
Zom: _ Outside Flood Zona? Municipal O On site disposal system O
Public O Private O Check it woo
SECTION 2: PROPERTY OWNERSHIP'
2.1 Own tot Roca d'
�C r✓�
Name(Print Address for Service:
Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(cbeek ON that apply)
New Conatnution O Existing Building O Owner-Occupied O 1 :pl*J, O Altention(a) O Addition O
Demolition O Accessory Bldg.O Number of Units__ Other O Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: ONlclal Use Only
Item i Labor and Materials
I. Building f 1. Building Permit Fee: f Indicate how fee is determined:
O Standard City/Town Application Fee
2 Electrical f O Total Project Cost'(Item 6)a multiplier ■
) Plumbing f 2. Other Fees: f
4. Mechanical IHVAC) f List:
s Mechanical (Fire f Total All Fees. f
Suppresiion2
Check No. _Check Amount: Cash Amount:_
-n Total Project Cost f 0 Paid in Full 0 Oubundmg Balance Due'
1
SECTION S: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
Licenw Number Evpoition Diu
Nype or('SL Hylder Li,a CSL Type Lee below)
a T Description
U I Unresmcud u to 17,000 Cu. ft.
R Restncted Ih2 FamilyDwelling
Srynimu .M Masonry Only
RC Residential Roofin Covering
w'
Telephone S Residential Window and sichrill
SF I Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. ISL f 2SC(6))
Workers Compensation Insurance affidavit must be completed and submined with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed AMdavit Attached? Yes.......... O No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by thin i��ldiing permit application.
/Z//('Z
Si 86 Date
ACTION 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 NNW
Signatuu of Owner or Authorized Agent Date
Si red under the pains and penalties o(perjury)
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 Home Improvement Contractor(HIC)Program), will y&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(CSLI can be found in 780 CMR Regulations 110.R6 and 110.R3, respectively.
2. When substantial work is planned, provide the information below
Total (loon area(Sq. Ft.) (including garage• finished basemenVantcs,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 ofheatmg system Number of deckL porches
Tvpeof cooling system Enclosed Open
1 "Total Project Square Footage'•may he.uhstituied for *Total Project Cost'
CITY OF SALEM
• PUBLIC PROPRERTY
DEPARTMENT
%W ai r.) !•nw ,+II
\I
I EI:978-74 9595 1'.\Y:978-740-9346
Debris Disp
osal Affidavit
Construction �e�r �
(required fur all demolition and renovation work)
State Building In accordance with the sixth edition of theg Code, 730 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit f# _ - _ is issued with the condition that the debris resulting from
this work shall he 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
(n:uneo aci ity)
(adl(ress nl lacillly) -
lature V"filrit applicant
/ z�)4
,late
Aq
CITY OF S.ULE.N1
PUBLIC PROPERTY
DEPART DENT
WjwW.1L"DA15LLX
%"VM 130we9m+GM"3TR"T•14LIK VwstAaRLssns 019V
TEi9'.a-7ti95" • Fen.97674&9$46
HOMEOWNER LICENSE EXEMPTION
Plea" Print
Data /Z l 6 D
Job Location
Home Owner Address 6 Ch.e J.-->
Home Owner Telephone 9 cs-r-- -7 S°/- 7 9 -5--
Present Mailing Address s :1-
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or less and to allow such homeowner to engage an individual for
hire who does not possess a license,provided that the owner acts as supervisor.
DEF24MON OF HOMEOWNER
Persons) who owns a parcel of land on which he/she resides or intentle 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 procedures and requirements.
HOMEOWNERS SIGNAMW
APPROVAL OF BUILDING INSPECTOR
See other side for state code