0003 CROMWELL STREET - BPA-10-843 v
r The Commonwealth of Massachusetts
} } � Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, T°edition OF SALEM
Revised JUrn/uw
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. NIOX
One-or Two-Family Dwelling
.� TlrikSeclion Fopbfficial Use Ortiz
Building Permit N I rb9ilDate Applied:
Signature: I ✓ —��— ��
Buildin ummissio er/ ns •t f ildings Date
CTION 1:SITE INFORMATION
1.1 roperty Address: 5,0e,a� 1.2 Assessors Map& Parcel Numbers
we—
L l a 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 11) Frontage(It)
1.5 Building Setbacks(ft)
MOwnerlofRecord: _
nt Yard Side Yards Rear Yard
Provided Required . Provided Required Provided
:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal!System:
Zone: _ Outside Flood Zone?
ate❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
cord: .( tr r1 Cgort. / -57 Address for Service: 'I
Signature elephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number o Units_ Other ❑ Specify:
Brief Description of Proposed Work'': r
h Ae— eAt. )
G
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Oliicial Use Only
Labor and Materials
I. Building s I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S O Standard City/Town Application Fee
❑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 Protect Cost: ,Sj� ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTR
UCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Dale
Name ol'CSL-Ilolder List CSL'I'ype(see below)
T Description
Address U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signature M Mason Only
RC Residential Rootin Coverin
-Ilephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or IfIC Registrant Name Registration Number
Address Expiration Date
Signature .Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 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 ..........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.
Si ture of owne Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
I J ,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
Prinl e S
Signature of O ner or Authorized Agent Date
Si ned under sins and nalties of du
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 ffgf 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 780 CMR Regulations I IO.R6 and I IO.RS,respectively.
2. 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
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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(f l:'17/•74{.•li4s •1'\f:'17/•7iS'1:1
Construction Debris Disposal Affidavit
(required fur all dcnwlition:urd renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR scetion 111.3
Debris, and the provisions of MGL c 40, S 54; MGL c
_ is issued with the condition that the debris resulting from
Building Permit N�_ rl licensed waste disposal facility as dafinod by
this work shall he disposed of to a properly
t 11. S 150A.
The debris will be transported by:
(110(Ile of hauler)
The rlcbris will be disposed Orin :
Sh ew. •
(nartlt ut aci Ity
I:IJdrleaa of facility)
.i aewe of permit appficara
date
CITY OF S.U.E.M
PUBLIC PROPERTY
DEPART LENT
SLLLK VA1fA00.sWrR mrro
n,-ra•ris•ssss• FAX 976.7+0.9"
HOMEOWNER LICENSE EXEIMMON
Please Prilst
Date
Job Locatim 3 Gt,)e,l.-o-It s St1/e k na f�
Home Owner Address <i G/la rn L,e-1(
Home Owner Telephone R 7 F --91Q-l6 77
Present Mailing Address 3 c.aow,4,c,11 5t Skl",- ;/km
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.
DEFINMON OF HOMEOWNER
Persons) 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 OQlcial, 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 requjrcpcntt
HOMEOWNERS SIGNATURE oli*
APPROVAL OF BUILDING INSPECTOR
See other side for state code