6 CHEVAL AVE - BPA-10-165 The Commonwealth of Massachusetts
i Board of Building Regulations and Standards CITY
I g OFSALHM
Massachusetts State Building Code, 780 C'MR, 7 edition
RrvirrJJmruun•
Building Permit Application To Construct, Repair, Renovate Or Demolish a /. :rxtiY
Onr-or Tsvu-Fumily �elhnR
is Section FopO.Mciall Use Only
Building Permit Number: Date Applied: O c"7
Signature:
Building Commissionck Ins to yifBu dings Date
S CTION 1:SITE INFORMATION
.1 r perry vr�. M� 1.2 Assessors Map& Parcel Numbers
'r 1.12 Is this an acce red street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
t�
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.3 Building Setbacks(11)
From 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: 1.3 Sewaga Disposal System:
Zone: Outside Flood Zone?
Public❑ Private❑ — Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 caner'of Reeord:
Nome(P ' t) Address for Service:
XSign ure Telephoro
SECTION 3: DESCRIPTION OF PROPOSED WORKS(cbeck all that apply)
New Construction❑ Existing Building❑ 1 Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specil)•:
Brief Descnp ion of Proposed Wo �
�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Omclal Use Only
Labor and Materials
I. Building S 1 1. Building Permit Fee:f Indicate how lee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Su ression Total All Fees:S
`) Check No. Check Amount: Cash Amount:
6. Total Project Cost: Sler/A' Gv 0 Paid in Full 11 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
of C'SI.• I Wider List C'SL Type(aee below)
fI Descriplion
Address U I IInrestricted(up to 35.000 Cu. Ft.
R I Restricted I32 Family Dwellin
Signature M I Masonry Only
RC I Residential Roulma Covering
Telephone WS f Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D f Residential Demolition
[;A�J—ld—mw
2 Registered Home Improvement Contractor(HIC)
C Company Name or HIC Registrant Name Registration Number
Espimtion Date
nature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.f 2SC(6))
Workers Compensation Insurance atTidavil 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
1 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. -
immure of owner Date
SECTION 7b: ERt OR AUTHORIZED AGENT DECLARATION
1 as Owner or Authorized Agent hereby declare
that t e statements and ' ormation on the foregoing application are we and accurate,to the best of my knowledge and
behalf. T �.
Signaturf of Owner or Aut 'zed Agent Date
(Signed under the pairs and nalties of 'u
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 aW have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations 110.116 and I 10.R5,respectively.
? When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basementlattics,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 of beating system Number of decks/porches
T)peof cooling system Enclosed Open
), "Total Project Square Footage"may be substituted for"Toal Project Cost"
CITY OF S.U.E.NI
PUBLIC PROPERTY
DEPARTNLENT
KlfOWJVY
MAVOR 130 WARUNGTON 971FST•Su914 MAZACHLS1r is 01970
ftL 97a•745-9S"• F.u1.97&7469646
HOMEOWNER LICENSE EXEM"ION
pk4m plat
Date X
Job Location e lg 2,0 �!
Home Owner Address
Home Owner Telephone 9 7 P= -2 c//-7 9S x
Present Mailing Address /o C/c,,w/ .fyea O/3'90 ly
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 posseas a license,provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Persons) who owns a parcel of land on which be/she resides or intends to reside. on
which there is, or is intended to be, a one or two family dwellin& 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 BUILDENG INSPECTOR / \
See other side for state code