14 CLEVELAND ST - BUILDING PERMIT APP 4
_ The Conunom+ealth oI MassachuseIIS — v
[ y IivarJ of Building Rrgulatiuns and StanJ;uJs I c llt
)
r Massac ILISCUS Slate Building Code. 780 (';SIR. 7"' editiolt \II NI('ll' \III 1
Building Permit Application To Construct. Repair. Reno%ate Or Demolish a K, I,,,,/A"M./, k (�,,
One- nr Trru-hiunilr DItelling 1. 'ur;S V
Fhis Section For Official llsr Only — - -- - - -- -- - —� Q�1
Building Permit Num r: _ Date Applied:
—/ -- --- --- -
Sienature: ✓✓
Bud n ( nnnisvune;i l— rut Buddm s -D.uc
_—. SECTION I: SITE INFORM FION -._.
1.1 Prup[ \ddres - 1 \sseuors Ala
4 V 0l > j--- p Pareel \unrh[rs
--
1-1_d Is Ih s an accepled .,loU:' yes no I \'rp illnnhCrher
/v .. tun` ._- ._—
I Zoning District PnrposeJ Use I Lot \r,a Isy IL !-1 uuta,c i I; I
1.5 Building Setbacks (t'i)
Font Yard T S;ur Yards Rear YarJ j
— —_—.
R eyui rrJ Prw.I(JetI Rcy!urcd —__
Provided Rcyuued P""'Llcul
r16Water upply: Itsi.G L c. 40. §sa) L7 Flood Zone tn•Torimation: I.SSewageD'S 'salSystein:Private ❑ Zone: ._ Ouuiu, Flood zone
_ Check �f yes❑ %lumcpal Won ;!lc Jislrrsal syslcm ❑
SECTION 2: PROPERTY ,iWNERSHIPt I
21 t!w �.t a`R cord:
ell
\.unr IPri
Sicn:!l;rrc
SECTION 3: DESCRiP•FION OF PR:)POSLD WORK'(check all that apply)
_ ding :ruun(s) ❑ Wdnirn ❑p ep:urs(s)NewCrns;ructiun ❑ ExitngBuil ❑
Demolition ❑ Accessory Bldg. ❑ Number r`f Units_ Other ❑ Spec;ly:
iBrief Deccriptior, of Proposed Work': - —_- -�
- -
' CTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(1_ah( r and Materials) Official Use Only
r1. Building_— $ I. Building Permit Fee: $ Indicate hos, fcc is Jetrrnn ned
2. Flectrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost' (Item 6) x multiplier _
3. plumbing $ 2. Other Fees: .$
a. .tilrrhanical (fiV:\C) $ List:
�. ;Mechanical (Fire i
Su r ressiun) Si Total All Fees:
('heck No. Check :\mount: (`ash :\ninon:i tr ['u[al Project Oust: $' I ---
❑ Pail in Full ❑(hnstandntg B:d:mce Due:
I
!
SECTION 5: CONSTRUE rIONSERVICES
5.l Licensed Construction Supervisor 1CSIJ
Lira nse Number If yn clutm DalI
i
..\ame of CSL milder Lul CSl.Tx pe orr hclowl _-- -
_
\ddre>•
l l me,illrted it'll la �S.INIU Cu hI.
R Resu'IaeJ L@'_ F.lmd" Der elfin¢
_— NI Nla onrn Unly
\I�nuuue _�
RC Rcsldenual Rlnlliuc
\\S Retldrnl1 al \\'utdt iw .Ind_lidl_yic
frlcpholic lF Ite,iJ:nli,ll tioliJ lvrl lit"nine \llli_tn__Ind_d l.itn ni-�i
D Re,ldrnu.11 Urmohuun __--
5.2 Registered Iloine Itnprovement Contractor(IIICI
— Rcpstrauun Nunlhrr
Ii IC Company Name or fI1C Registrant Name
Addres> Expuauan Data
Teleplunle
Signature _
SECTION 6: WORKERS' COM1IPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. 5 25C(fr))
Workers Compensation Insurance affidavit muss be completed :old submitted with this application. Falurc to pelt IJe
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached'! Yes .......... ❑
Nu . . ❑
SECTION 7a: OWNER A ORIZATION I BE COMPLETED WHEN
OWNER'S AG OR TRACTOR APPLIES FOFt BUILDING PERMIT
as Owner of the subject property hereby
to act on my behalf, in all nratmn
iAuthorizr - - — — .—.—
i
re!ative to v;,.�Ik authorized by. t bu 'n- rmt app!ieat rilDate
SI IlalUic•tit owner
S CTION 7 : OWNEW OR AUTr ORIZED AGENT DECL:IRATION
as Owner or Authorized Agent hereby Jeclure
1.
on the foregoing application are true and accurate, to the best of my knowledge and
that the statements and information
behalf.
Print Na
l C Dat '
Signature of Owner or Authorized Agenl
(Si ned under the 2ains and penalties of erju 1 -__.
NOTES: {
I. An Owner who obtains a building permit to Jn his
own work, or an owner who hires an umegl,tered alnlr'1`("(
(not registered in the Horne Improvement Contractor (HIC) Program). will not have access to the ;ublu'allon
program or guaranty fund under M.G.L. c. 112A. oc7 er important information on the HI(' Program and
( nstruc(l n Supervisor Licensing mg WSL)can be totmd*m 780 CvIR Regulations I I0d26 :md 110.125. respertncly.
' When substantial work is planned, plo�lde the information below:
i - (including garage. finished basementlat«cs. decks ur pt'rch'
Total floors area l Sy. Ft.) _ Hahiiahle room count
I (;loss liv.mg area ISy. Ft.) Number of hednnan,
Number kit tlleplaces Numbertit hall/baths --.---- -
I Number of hathruoms Number of Jccks/ pl,rchc, ..-----
fcpe of heating system _ LncltoeJ
TNpe )I "" log system
1. "Total Project Syu:lre Footage• may be sub,ttuted tit " Total Project Cost',
CITY OF S.U.EM
PUBLIC PROPERTY
DEPARTMENT
KJMSEMV 00ZCC "
MAVOK 130 wA9 b=M STMUT 9 S AK MMACXI.'SUM 01970
7*1:TW745-MS• FAx 975-740.9M
HOMEOWNER LICENSE EXEMPTION
Pleas Print _
Date c s7
Job
Home Owner Addreu
Home Owner Telephone
Present Mailing Address
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 supervisor.
DEFINITION 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 tan a City of Salem
Building Department minimums inspection ad rements and that he/she
will comply with said procedures and r it
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code