2 FOREST AVE - BUILDING INSPECTION n /\ The Commonwcalth of Massachusetts Town of
p1\ Board of Budding Regulations and Standards �~
t\ VY Massachusetts State Building Code, 780 CMR, 7"'edition Building Dept
Budding Permit Application To Construct, Repair, Renovate Or Demolish a *k
00000
One- or ruv-Funuls'Dsi'ellln
This Section For Q(recialyOsAiDnly
Building Permit N ber 4e
0 Signature. O /
Building Commissioner Inspector of Buddl Date
SECTION 1 INFORMATION
LlyrSddrs:es ✓ ifLI Assessors Map b Parcel Numbers
Ate
1.1 a Is this an acce led street?yes no Map Number Parcel Number,
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use La Arco(sq fl) Frontage 1 R)
13 Building Setbacks(ft)
From Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Public O Private O Check if s0 P
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: /—
,ZAneS'Tt ✓e 4- 7 '7/Z4s'r' 2 � tit fly
(Pr ) - Address forService:
�177 777 XI10
Signat - Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction O Existing Building O Owner-Occupied O Repairs(s) O Alteration(s) O Addition O
Demolition O Accessory Bldg.O Number of Units_ Other O Specify!
Brief Descriptio of Proposed Work':
W
ECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Ofllclal Use Only
Labor and Materials)
ng f I. Building Permit Fee: f Indicate how fee is determined:
❑Standard City/Town Application Fee
cal f O Total Project Cost'(Item 6)x multiplier x
ing f 2. OtherFees: fnical IHVAC) f List:
ical (Fire f Total All Fees: f
onCheck Vo. Check Amount: Cash Amount:roject Cost: f 3o O 0 paid in Full O Ouutandmg Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supers isor(CSL)
L.cenve Number Expiration Date
^Drat of CSL Ilylder List CSL Type(we tic-low)
--- Ts or Description
Address U Unrestricted f up to 35.000 Cu. Ft.
R Restricted 1&2 Family Dwellinst
Signature M Masonry Only
RC Residential Roofing Covering
Telephone w'S Residential Window and S,dm
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.3 Registered Home Improvement Contractor(HIC)
HIC 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 Milli))
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
), 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:OWNERI OR AUTHORIZED AGENT DECLARATION
I,�14.4 it P r ,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.
�r Z'o,)
Print N" im/rxe, s
Signature of Ow or Authorized Agent Dste
(Signed under the 2ams and penalties of r
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
tool registered in the Home Improvement Contractor(HIC)Program).will=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 l0.R6 and 110 RS, respectively.
2. When substantial work is planned,provide the mfornimion below:
Total floors area(Sq. FL) (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 Laths
Type of heating system Number of decks/porches
Tspeofcoolingsystem Enclosed Open
3 "Total Prolecl Square Footage" may he substituted for 'Total Project Cost'
CITY OF S E.NI
PUBLIC PROPERTY
DEPARTMENT
[110fJ1aY w.n.
N..vw i 3D a►..s«o.crn.sneer•snual NnAMoftscrn mro
rlu.9'8-74s•9s"• F.�lc 9'L7�69W
HOMEOWNER LICENSE EXE.M"104N
Pktase frrirt
Date /o 4L, 5�
Job Location Axe-3- 7 4 k e 14le , -
Home Owner Address 2� v e T T S T Pe/'kel'
Home Owner Telephone q 9 9 7 7 > -2 9
presser Mailing Address Ac v T s -
,'s Pj"� a
The current exemption of"Homeownere was extended to include owtteroccupied
dwellings of two Units or less and to allow such homeowners to engage an individual for
hire who.dos not posse"a licenser provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s) who oats a patortl 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
stnscnm accessory to such use and/or farm structure. 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"assume 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 equira7rits.
HOMEOWNERS SIGNATURE
,aPPROVAL OF BUILDING DiSPECTOR
See other side for state code
Y � ,
CITY OF SALEM
ISL
PUBLIC PROPRERTY
�-r',f DEPARTMENT
4 ;5
til S.urM. MAN"
'I'rl:978-74 9595 •f.t%:978J40-')846
Construction Debris Disposal Affidavit
(required I-or all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit _ - _ is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
S 150A.
The debris will be transported by:
�f C',9-/t rir9
(112111C of hauler)
The debris will be disposed of in
- p,ame of aci 1io
(address of tacility)
natuee of permit applicant
date
-Ichn vll i!ue