17 CHESTNUT ST - BUILDING PERMIT APP The Commonwealth of Massachusetts Town of
� Board of Building Regulations and Standards
;; Massachusetts Slate Building Code, 780 CMR, Tx edition
Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Ttca-Fomilc Duelling
This Section For tcial Use 3pnly
Building Permit No `r/�I - D e plied:
Signature: vim/ y /
Building Commissioner/Inspetflorof Buil ings Date
SECTION 1: SITE INFORMATION
I. pertly AdQress 1.2 Assessors Map& Parcel Numbers
1.1 a Is this an pyaccc�cepted street?yes )` no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) i Frontage(11)
1.5 Building Setbacks(D)
Front Yard Side Yards - Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c. 4Q S54) 1.7 Flood Zone Information: 1.9 Sewage Disposal System:
Public O Private❑ Zone: _ Outside Flood Zone?Check it es0 I Municipal❑ On site disposal system ❑
I
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
zAa jkiI(J r e
Name(Print Address for Service:-
--$! SSG Io� f�
Signatur Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction Existing Building❑ Owner-Occupied ❑ Repairs(s)A( Alteration(s) ❑ Addition ❑
Demolition Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief De cription of Proposed Work': i & _� °
L... j .on o Oe
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 011iclal Use Only
Labor and Materials
I. Building f n— /O K 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical f ❑Total Project Cost'(Item 6)x multiplier x
J. Plumbing f 2. Other Fees: f L�
4. .Mechanical (HVAC) S List: �_ )t( 0
5 Mechanical (Fire S Total All Fees: S
Suppression)
Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: S /`—) /OIL' 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
" - License Number Expnauon Date
Nyse of CSL Helder List CSL Type(wc below)
T Description
Address
U Unrestricted(up to 35,000 Cu. FL)
R Restricted 1&2 Family Dwellin
Signature M Masonry Only
RC Rcstdcnual Roofing Coverin
Telephone WS Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Tclephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 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
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 this building permit application.
Si nature of Owner Date
/ SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1, F/L 4V6o t S A- V t isi ,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.
r/4Auc-01S GLy( vW
Print NYu, h
er or Authorized Agent Date
sins and nahies of r u
NOTES:
[2.
. 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 W have access to the arbitration
program or guaranty fund under M.G.L. c. 102A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I0.R6 and I IO.RS, respectively.
When substantial work is planned, provide the information below:
otal Doors 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 healing system Number of decks/porches
Ty pe of cooling system Enclosed Open
3. 'Total Project Square Footage'may he substituted for"Total Project Cosy'
CITY OF SALE.Nf
A '
PUBLIC PROPERTY
DEPAR-T.LENT
K11vl1liY N.fl'1Y 1
MAVCG 130 wASUNGrON STU=•SMFK NA4A01lSSr1S 019-0
TEL 9'.L7JS-9S"* F%x 978-740-964
HOMEOWNER LICENSE EXEMPTION
Please Ftlrat
Date &/Q0 /
Job Location
Hoare Owner Address_/� Chin a Su le,, .lt�e2
Home Owner Telephone / 6 <e
Pramt Mailing Addrw A-- ^, I- 41 )ig-?d
The current exemption of"Homeowners"was extended to include owner-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 supervia w.
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 procedures and requirements
HOMEOWNERS SIGNATURE —
APPROVAL OF BUILDING INSPECTOR
See other side for state code