173 FEDERAL ST - BUILDING INSPECTION (4) V 1 The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
t� Massachusetts State Building Code, 780 CMR, T°edition OF SALEM+� Revised Junnury
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Fumily Dwelling
This SectiqaXQr Official Use Only
Building Permit Number: ate Applied: n
Signalurei! S' CZ- LQ ZXV4,Z �J ,G///O
Building Commissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 P em Address A n S� 1.2 As rs Map& Parcel Numbers I
ccepted street?yes_I.Ia Is this an e no P Ma Number Parcel Number
a .
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water upply:(M.G.I,c.40,§54) 1.7 Flood Zone Information. - 1.8 Sewage Disposal System:
Public Private❑ Zone: _ Outside Flood Z e7 Municipal❑ On site disposal system ❑
Check if yes
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record•
-q N rA atU t- A nL c L}�i (-el� Oa
4
Name i rim) Address(or Service:
j Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Descripti n of Propos d Work-: - In t Z ? °
cutwul; i z e ' �i W1
i d m 6 X Lukll5
t
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
. Plumbing S 2. Other Fees:
4
. Mechanical (BVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
Check No. Check Amount: Cash Amount:
6.Total Project Cost: S 5t,)1600 , pD ❑Paid in Full O Outstanding Balance Due:
i
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
I.icense Number Expiration Date
Name ol'CSL• I holder List CSL Type(see below)
.f Description
Address U Unrestricted(up to 35.000 Cu.Ft.
R Restricted 1 @2 Family Dwellinit
Signature M Masonry Only
RC Residential Routing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Buming Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
111C Company Name or HIC Registrant Name Registration Number
Address Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 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 ..........❑ No...........0
SECTION 72: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
, 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.
Shutature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
I ,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.,
k 14 K�4 1 A_
Print Name
Signature of Owner or Authorized Agent Date
(Si tined 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 no.1 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 780 CMR Regulations I IO.R6 and I I O.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
J. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF SALEM
�i PUBLIC PROPRERTY
DEPARTMENT
a
>I . ,lotnlrl.y76.1.{ /i I! �`I ,!c''17t•.•IS'IIIJA 1,.:1'I':
Construction Debris Disposal Affidavit
(required fur all demolition and renovation work)
In accurdaanc with the sixth edition of the State Building Code, 780 CMR section 1
provisions of MGL c OU, S
Debris, and the
Building Permit !►�_- . _ is issued with the condition that the debris resulting from
this work shall he dislwscd o n a prope
.irly licensed waste disposal facility as defined by MGL c
It1. S 150A.
The debris will be transported by.
lnamasot'haulerl
The debris will be disposed of in
(n.YfK U1 DU lay
laddras or rarllilyl
.Irma eufl,crmit,apphcant
Jals
CITY OF SALE.Nf
PUBLIC PROPERTY
DEPARTMENT
w.�..ar D.Qr.y
V..we 130 WASWAGM M shear•s u a— MMIAG&SWM Otfl'0
Ni 9-9-745•gsss • f:As 973•74o.9646
HOMEOWNER LICENSE EXEIMMON
Please Print
Date 7 - d
Job Location
Home Owns Address 2 -
Home Owner Telephone
Present Mailing Addoas
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 hdshe understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATL� �o'
APPROVAL OF BUILDING INSPECTOR
See other side for state code