30 CROWDIS ST - BUILDING PERMIT APP �6 - lLl 086
Hie Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
4J( l Massachusetts State Building Code, 780 CMR SALEM
Reviser[Mar 2011 i
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or 71vo-I ainily Dwelling
This Section For Official Use Only
Building Permit Number: Dat Applied: r ) . I
Jai �y
Building Official(print Name) Signature Da e
SECTION 1: SITE INFORMATION
L IProperty Address: 1.2 Assessors Map& Parcel Numbers
300U1�PS Si 14Ai_�tvl-LiA Ofy
1.la Is this an accepted street?yes_)<_ no Map Number Parcel Number
1.3 Zoning Information: IA Property Dimensions:
Zoning District Proposed lJse Lot Area(sq 11) Fronlugc(11)
1.5 Building Setbacks(f)
Front Yard Side Y;uds Rear Yard
licyuired Providod Required Provided Required Provided
1.6 Water Supply:(,%LG.L c.40,§54) 1.7 Flood 'Lone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zonc?
Check iryes❑ Municipal❑ On site disposal system ❑
SECTION2: PROPERTYOWNERSHIP'
2.1 Owner'of Record:
5DLrAaClf _ _SBI �iJl FMA O1cl�
Name(Print) City,State,ZIP
�4S,LA-/VL, sr�rvt
No.and Street Telephone Email Addressuy.;e6er
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ I2epairs(s) ❑ Alteratiun(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed work`: .j'nG Tq_LL, T;D Of W �—f
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials) y
I. Building $ I. Building Permit Fee: $ Indicate how tee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x_
3. Plumbing .$ 2. Other Fees: $
4. Mechanical (IIVAC) $ List:
5. Mechanical (Fire -_
Su t ression) S Total All Fees:.S_
6. Total Project Cost. S -5,4,0 C) �.�1 Check No. _Check Amount: Cash Amount:
. V ❑ Paid in Full ❑Outstanding Balance Due: -
c_JGI V 1 To �-L --
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSI.'Pype(see below)
No.and Street 'rype Description
11 Unrestricted(Buildings up to 35,000 cu. fiJ
R Restricted 1&2 Fatuity Dwelling
City/Town,State,ZIP M Mason
ry
RC Routing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
I IIC Company Name or HlC Registrant Name
No.and Street Email address
City/Town,State,ZIP 'fete hone
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 7n: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject properly,hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW 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 knowledge and understanding.
C2�(--?K A W LLr 2� 6. f-4 • /4
print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 not have access to the arbitration
program or guaranty fund tinder M.G.L.c. I a2A.Other important information on the HIC Program can be found at
www.nt1ss.1.tov/oca Information on the Construction Supervisor License can be found at wwtv.mass.eov/dos
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. fl.)_ Habitable room count
Number of fireplaces Number of bedrooms _
Number of bathrooms iNumberofhalf/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, MASSACI IUSETTS
BUILDING DEPARTMENT
tr ! 120 WASHNGTON STREET,3"D FLOOR
TEL. (978) 745-9595
Fix(978) 740-9846
KINMERLEY DRISCOLL
MAYOR TY-IOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONLvUSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date (� . ):�
Job Location
Home Owner Address rS si Sao LF_1" V'sA Q 199-
Present Mailing Address Jel-I-tE
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 that 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 understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR