2 CRESCENT DR - BUILDING PERMIT APP C av
The Commonwealth of Massachuseus
• Not Board of Building Regulations and Standards CITY
Massachusetts State Building Code. 780 C'MR, 7'"edition OF SALEM
xrs•ised Junu.vs•
� Building Permit Application To Construct, Repair. Renovate Or Demolish a
ti one-or rwo-Family Dwelling
Thi on For Official Use Only
Building Permit Number: ZDate Ap -/V- /O
Signature: ' /�/�
Huilding Cummissianed Inspectaru uil Date
CTION 1: SITE INFORMATION
1.1 Property Address: / 1.2 Assessors Map R Parcel Numbers
L l a Is this an accepted street?yes no Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use La Ares(sq 11) Frontage(11)
1.5 Building Setbacks(11)
From Yard Side Yards Rear Yard
pl.6Wzter
d Provided Required Provided Required Provided
Supply:(M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Private O Zone: Outside Flood Zane? Municipal O On site disposal system OCheck if esOSECTION 2: PROPERTY OWNERSHIP'
r'of Record:
) Address far Service:
Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building Owner-Occupied 1(( Repsirs(s) Alteration(s) O Addition O
Demolition O Accessory Bldg.O Number of Unit_ Other O Speciry:
Brief Description of Proposed Work-: a DO
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Omclal Use Only
Labor and Materials
I. Building IS �.SOO.O O 1 I. Building Permit Fee: S Indicate how fee is determined:
Standard City/Town Application Fee
?. Electrical S O Total Project Cost(Item 6)x multiplier x
J. Plumbing S 2. Other Fen: S
4. Mechanical (HVAC) S List:
S. Mechanical (Fire S
Su ression Total All Fen:S
Check No. _Check Amount: Cash Amount:
6. Total Project Cost: 5 p Paid in Full 13 Outstanding Balance Due:
SECTION!: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor ICSL)
License Number Hapiratiun lyale
Name of CSI.- I lulder I.ist CSL Type(see below)
r Descri ion
:Address U Unrestricted u lu 1%nnn Cu.FI.
R Restricted IR2 Family Dwellin
Signature M I masom only
RC I Residential Routing Covering
fcicphone WS I Residential Window and Siding
SF Reiidenlial Solid Fuel Burning Appliance Installation
D Residentiol Demolition
F�;Aid—dma
e Improvement Contractor(HIC)
r f 11C Registrant Nume Registrmion Number
Expiration Date
Teleplturue
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. ISL 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 7n: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.
Signature of Owner Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
c3-e�(, t^-f C37 r--1 ✓6-, to ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the but of my knowledge and
behalf.
j rr t ✓tea �
Print Nam"
Signature of Owrwr or Authorized Agent Date
(Signed under the pains and Penalties of 'u
NOTES:
I. 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 rW 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(CSL)can be found in 790 CMR Regulations I IO.R6 and 1 IO.R3,respectively.
�. When substantial work is planned,provide the information below:
Total floors 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
). "Total Project Square Footage"may be substituted for-Total Project Cost"
k. j I Y C )V JNLLIVI
� I PUBLIC PROPRERTY
~.`4 - ' DEPARTMENT
I:C \\ J IIV..� •.11�llf � 1\II \L \L\. 0
Construction Debris Disposal .affidavit
(icyuited lix all demolition and renuvatiun work)
In accordance %6111 the sixth edition of the State Building Code, 780 CNIR section 1 1 1.5
Debris, and the provisiuns of N1GL c 40, S 54;
Building Permit is issued with the condition that the debris resulting from
tt
this work shall he disposed of in a properly licensed waste disposal facility as defined by V1GL c
I11. S 150A.
The debris will be transported by:
n7�. � ry 1 vt�✓
I narnc( l'hauler)
The debris will be disposed ofin
(nalnr ul laci ity)
I�ulJres� ul laclhty)
.Icnalwc nl permit apphunt
daw
. CITY OF S.�I_EM
PUBIIC PROPERTY
DEPARTtiiENT
w�at.tar,,....,..
VAron t 3p WAtaWWMN STUXT•sAu^M. Aneoatsrrn el970
nI r.11-7-9s" • F%x 9-8L7+0.9a4
HOMEOWNER LICENSE EXEMPTION
Please Print
Date !D -/K
Job Locatica o2 Cl ---rno , Yz- �✓^
Home Owner Address j2 1 �^
Horns Owner Telephone —
Ptesent Mailing Address o.2 a-r-� _
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.
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
"homeownee 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
c
APPROVAL OF BUILDING INSPECTOR
See other side for state code