50 DERBY - BUILDING INSPECTION JACKET The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
ppp t ,n OF SALEM
1
Massachusetts State Building Code, 780 CMR, 7 edition 1 1 Rrci card Juno<iry
Building Permit Application To Construct, Repair, Renovate Or Demolish a /• --'/)/hY
One-or Trvu-Ftuni1v Dwe ing
This Section For Ott- ial Ose Only
Building Permit Numb Da Ap ied:
Signature: A"Q
Building Commissioner/Inspector of Buildings Date
M1�
SECTION I:SITE ORMATION
1.1 Property Address: 1.2 Assessors Map & Parcel Numbers
I.1a 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 III)
Front Yard Side Yards Rev Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L e.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone'? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑ p P y
SECTION2: PROPERTY OWNERSHIP'
4—Nume(
wnert of Record:
sa
int) Address for Se ice:
F'> �uY / 3 g��ss3 3re Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Briet'Dgscription of Proposed Work':
Gam• l —ta ri.1 e --Fie- r �J
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
I. Building S 1. Building Permit Fee:S Indicate how fee is determined:
�. Electrical S ❑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
Suppression) Total All Fees: S
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S ❑ Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
I.icense Numt cr li.�pimlion Date
Naunt ul'C'SL• I luldtr
List C'SL type(see below)
I Noe IDescription
Address
IJ l4trestricttd u to 35,W0 Cu. "
ItRestricted I&2 Pamil De'owl n
Signutur ' M M:uun Unl
RC Residential Ruolin overin
Telephone WS I Residential Win wand Siding :
SF Residential Solfi Fuel Burning Appliance Installation
D Residential Demolition
s-
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or IIIC Registrant Name Registration
AJdress
L.epirquun Date
Signature Tcltphone
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 .......... 17 No...........❑
SECTION 7a-,aWNERAXTIiORIZATION TO BE COMPLETED WHEN
OWNER'S ENT OJCCO RACTOR APPLIES FOR BUILDING PERMIT
X 1, 6 //J , 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:OWNEW OR AUTHORIZED AGENT DECLARATION
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.
Print Name
Signature ol'Owner or Authorized Agent (late
(Signed under the pains and penalties of er'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 not 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 790 CMR Regulations I IO.R6 and I IO.RS, respectively.
2. When substantial work is planned,provide the information below:
Total flours 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 halt%baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may he substituted for"Total Project Cost"