2 FOREST AVE - BUILDING INSPECTION (2) The Commonwealth,,IMa,,,acliL,sotts CITY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CNIR Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One or Two Family Dwelling
Thrs Section For Ittrat,Use,Only
T" A tied
Build Number
Permit aiPP
]3uildihg Official.(Print Ndrhe) ,.��'
;SECTION'�:L SITE'
FO, IT
1,1 rop Ly Address: .2 Ass ors M areel Numbers
1.1 a Is this an accepted street?yes� no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Lot Area(sq ft) Frontage(ft)
Zoning District Proposed Use
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c. 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public ' Private 0 Zone: Outside Flood Zone.? Municipal M*'G-n site disposal system ❑
Check if ycs;13�
SECTION PROP72T1
0, ERSH IP
2.1 Own ri of Record:
Te,4✓ Zll�,1 //2 0?0 0/ M 4 0 / y z�°
Name(Print) / City,State,ZIP
-9Vr .20 <,e r 7- 5- T- o779 777,W9 In- Veen-* I e 6/Pg i r-x)- "el
No. and Street Telephone Email Address
SECTION
E TIO 3i.DESCRIPTION PROPOSED
WORK' (check a. thaa t,apply}
----------
New Construction 0 Existing Building 0 Owner-Occupied 11 1 Repairs(s) B— El] Alteration(s) 0 Addition
,Demolition 0 Accessory Bldg. El I Number of Units Other 11 Specify:
Brief Description of Proposed Work':_i9qu//t A a J
SECTION ,F$Tl
T ED CONSTRUCTION COSTS"'
4
Estimated Costs:
Official On
Item (Labor and Materials
7 00 — , ri 9 ildinglL d"
I. Building Z I B Permit Fee ��Q z�Indicate how feels determined
L
':Cit—y - "
Lb Standard Application Fee,
2. Electrical $
- '6'T6taLProje6t V (ItemX U tjpV
3. Plumbing 2:, OQ6`rtees '
42:>,
�
4. Mechanical (HVAC) $ Ltst
S. Mechanical (Fire
Total All Fees: $"
Suppression)
Check No. heck Amount Cash Arm)uht"_'�
77 9 7 6. Total Project Cost:
El Paid in Full [3 Outstandin _8al�ffic&-Du&
SECTION 5: CONSTRUCTION SERVICES
r�fC
truction Supervisor License(CSL)
R r C [ License Number Expiration Date
SL HolderList CSL Type(see below)
. eet `?Type Descnpt en ;
09 8�� � U Unrestricted n(Buildings up to 35,000 cu. ft.)
R Restricted 1&2 Family Dwellin
City/F6wn, State,ZIP M Masonry
RD
"Deolition
Roofing Covering
nd'Siding
Burning Appliances
(�O°
Tele hone Email address 5.2 Registered Home Improvement Contractor(HIC)
on Number Expiration Date
HIC Company Name or HIC Registrant Name
No. and Street
Email address
Ci /Town, State, ZIP Tele hone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G,L:c. 152. g 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 It
Attached? Yes .......... Cl No ........... ❑
SECTION 7a: OWNER AUTHORIZATION-TO BE COMPLETED WHEN'
OWNER'S
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT` "
I, 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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTFIORIZED AGENT DECLARATION "
APrint
tering my n ne below, I hereby attest under the pains and penalties of perjury that all of the information
ned in thi pplication is true and accurate to the best of my knowledge and understanding.
�/ l� 3 �lz
v 's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. 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. 142A. Other important information on the HIC Program can be found at
wv,w-.rnass.gov/oca Information on the Construction Supervisor License can be found at www'.mass.eoehlns
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. 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 Ja�L E� t, UNsSACHUSETrS
t . R ILDNG DEPARMEINT
130 WASHLNGTON STREET, 3" FLOOR
TEL (978) 745-9595
FAx(978) 740-9846
(G.NtBFRt FY DRISCOL.L
Twsw ST.PtERRa
DIRECTOR OF PUBLIC PROPERTY/BUUMDtG COSaIISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section it 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit It is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11, S I50A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in :
(name of fa6lity)
(address of facility)
azz
sig tare of permit applicant
date
drbn.alt.�i N:
CITY OF SMXL Nt
PUBLIC PROPERTY
DEPARTaNIENT
� u.aasY o•sraaL
�..raa i b w�o•w,�v.tr•aaT•s•urs Vwa,�oazarrs otr.o
r>s.s-ar,s-ss+s• t<..,�.r-tL�,o.sw
HOMEOWNER LICENSE EXEMPTION
Mass "I
Date-1 /1a 3 L/2
Job Loeados a
Home Owner Address
Home Owner Telephone 9 I A 3 >7 .53 3
Presed Marlins Address ?o wPs T S T &o,�ve-iu rl .4...4 a,9 2-7
The currant exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or iw and to allow such homeowners to engage an individual for
hire who.doom not posses a Hcros4 provided that the owner acts as supervisor.
DEFINMON OF HOIWOWNMt
Person(s) who owns a pared of land on which befshe resides or intands to resider on
which there is, or is intended to ba,a one or two firmly dwelling, attached or detached
structures accessory to such use and/or farm structures. A pawn who constructs more
than one hone 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 understands the City of Salem
8uildiag Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF SWUNG NSPECTOR ��
See other side for state code