5 FOREST AVE - BUILDING INSPECTION yI l ( S ale 5� 3 h• I �O TfOMepwne �
The Commonwealth of Massachusetts
�y Board of Building Regulations and Standards Town of
kj Massachusetts State Building Code, 780 CMR, 7" edition
Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Olrelling AWOL
This Section For Official Use Only
Building Permit Numb Date Applied: q
Signature:
Building Commissioner/Ins or of Buildings Date —�
SECTION 1: SITE INFORMATION
\ ^ 1.1 Propert Address* 1.2 Assessors Map& Parcel Numbers
Ma
I.la Is this an accepted street'. yes ,/ no P Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq C) Frontage(It)
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:
Zone: _ Outside Flood Zone?
Public' Private❑ V
Check if e ` Municipal On site disposal system [3
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Re ord:
s�sQ s � e�
Name Addteas fut Setviue:'�I� —
Signature Tele h7 C ( £ ! (
SEC ON 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New eonstruction❑ Existing Building Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work':
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. ElectricalS ( 6 ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 0 d 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S ZO D 0 0 Paid in Full 0 Outstanding Balance Due:
n
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
hr., License Number Expiration Date
Namc of CSL- Helder List CSL Type(see below)
Type Description
Address U Unrestricted(up to 35,000 Cu. Ft.)
R Restricted I&2 Family Dwelling
Signature M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burriing Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) ,I
HIC Company Name or HIC Registrant Name Registration Number
Address Expiration Date
Signature Telephone
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 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
:rclative
as Owner of the subject property hereby
ze _ to act on my behalf,in all matters
to work authoriz b rlding permit application.
re ofof0 r / Date
ION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1 ,��— ,as Owner or Authorized Agent hereby declare
that the statements and mformation oithe foregoin application are true and accurate,to the best of my knowledge and
behalf. -- q
Print Name
Signature of Owner or Auth riz d g Date O V
Si ned under the ains a al o r u
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I0.116 and 110.R5,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
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF S UEM
PUBLIC PROPERTY
DEPARTMENT
iu�o��n.".•.ti
%1AV0a 130 wA94NG'Tq1 STUNT 9 SLL816 NA=%CHL>aM 01970
Tbl 976-745-9S"• FAx 971-74&M"
HOMEOWNER LICENSE EXE.MMON
Please Print
Date� T
Job Location
Home Owner Address
Home Owner Telephone - - q 0
Present Mailing Address
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 he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and re uirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPE OIP// Ok
See other side for state code
=" CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
;I
I I I . v-s-'4; );4); • 1'\x. 'i7s V,;'1fi4,,
Construction Debris Disposal Affidavit
(re(luired 1br all demolition and renovation work)
In accordance %%ith the sixth edition of the State Building Code, 780 CMR section 1 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit 1t 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
I1I. S 150A.
The debris wibe transported by:
(name of harder)
I lie debris will be disposed of in
(uamr ul lacility) -
(address ul lacilav)
V
sigmalUK"5 f ,plicant
/- � - 047
date