16 CHURCHILL ST - BUILDING INSPECTION \ The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SdMar
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number.' ' Daf plie' ///»ww
Building Official(Print Name) r :Sign ur Date
SECTION 1: SI TION
1.1 Pro erty dr ss: 1.2 Assessors Map&Parcel Numbers
/(� MILL ST alp _ 013 y
I.Ia Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(8)
1.5 Building Setbacks(ft)
Front 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:
Zone: Outside Flood Zone?
Public El Private❑ Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: 'PROPERTY OWNERS13IPi„
2.1 Owners of Recor -.
/ ame(Print) City, State,ZIP
I l o G1Gy2V1GC 5% d d i i
No.and Street -r-- Telephone Email Address
SECTION 3: DESCRIPTION-OFPROPOSED WORK",(check all that,apply)
New Construction❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work 2:
0 4o , Ql 4_
SECTION 4 ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Labor and Materials) r Official Use Only
a,
1. Building $ 1: Building Permit Fee $' ` : Ixidicate'how fee is,determined:
❑ Standard City(Town Application Fee i
2. Electrical $ ❑Total Project Costa(Item 6)zmultiplier ' x'k
3. Plumbing $ 2:OtherFees: $ s
t �
4. Mechanical (F VAC) $ List:
5. Mechanical (Fire
Suppression) $ Total All Fees: $ `
/� Check No ='Check Airiount �Cash Amount
6. Total Project Cost: $ / 1� ❑Paid in Full „ €`❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder -
List CSL Type(see below)
No. and Street e z�=Type ?� �„ s ,° .D$scription„�'.-
U Unrestricted(Buildings u .to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/Town, State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
H
HIC Company Name or HIC Registrant Name IC Registration Number Expiration Date
No.and Street Email address
City/Town, State,ZIP Telephone
SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 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:7a: OWNER AUTHOWZATION TO BE COMPLETED'
OWNER'S AGENT, OR CONTRACTOR APPLIES F^OWBpUILDIN/G PERMIT
I, as Owner of the subject property,hereby authorize bA
to act on my behalf,in all matters relative to work authorized by this building permit application.a
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNERi=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 knowledg&and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
- 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 not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at
wcvu.rnass, og v;'oca Information on the Construction Supervisor License can be found at www.mass.eov%dns
2. When substantial work is planned,provide the information below:
Total floor 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 half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
P'
CITY OF S.U.E1NI, NWSACHUSETI'S
Bu=NG DEPARTJIE,�1T
• J°• 130 WASHINGTON STREET,3° FLOOR
T EL (978) 745-9595
FAx(978) 740-9846
KINtBFRT RY DRISCOLL
MAYORTHO4tAS ST.PIERRS.
DIRECTOR OF PUBLIC PROPERTY/BUILDL\G CO%LMASSIONER
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 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# is issued with the 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:
(name o hn�)
The debris will be disposed of in
(name of facility)
(address of racility)
signature of permit
as lican[
date
lebrisall:J<w
CITY OF S.U.E%f
PUBLIC PROPERTY
DEPARTMENT
u,ouasr a.utaa+
' wvae t�v��sn.ar�ssuaa Vsateaasasis Olfa '0
HOMEOWNER LICENSE EXE.HPTIOV
Please Ftriet
Date 6 g-1 y,)6 a
Job Locados S IA-L-e oy1
Home Owner Address i( r CGt eU cct
Home Owner Telephoae� 7 VV-
Praant Mailing Addiao 114 PAI-OPPW-ML S7 - S, 1614� 21124
The current exemption of"Homeowner"was extended to include ow nw-occupied
dwellings ottwo Units or feat and to allow such homeowner to engage an individual for
hire who does not possess a licenser provided that the owner acts as supervisor.
DE INMON OF HOMEOWNER
Person(s)who owns s psreel otland on which Wafts resides or intends to resider on
which there is, or is intended to bs6 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
'•homeownee shall submit to the Building Of11ci4 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'assume@ responsibility for compliance with the State
Building Code and other applicable bylaws and regulations.
The undersigned "homeowner'certifies that helshe understands the City of Salem
Building Department minimum inspection procedures and requirements and that helshe
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state coda