16 FORRESTER ST - BUILDING INSPECTION (3) e
Zk The Commonwealth of Massachusetts
] BoardofBuildingRegulationsandStandards CITY
Massachusetts State Building Cud . 780 CMR. V"edition OFSALF M
���,�
Revised Junuarn-
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-FomilP Dwelling
is Section For Official Use Only
Building Permit Number: J Date Applied: POW _
Signature: 4& &1 S
Building missioner/Ins0flor of4luildinp Date
SECTION 1: SITE INFORMATION
�( 1.1 Proppferty Ad reas: 1.2 Assessors Map& Parcel Numbers
/& kyrres .Lp. 4
I.I a Is this an accepted street?yes ✓ no Map Number Panel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lm Area(sq 11) Frontage(11)
1.5 Building Setbacks(ft)
From Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if es❑ Municipal 0 On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2. Ownert o1f 1Record:SET�F.0.r7J 16TrresF�r- �f
�Name(Pei Address for Service:— %,7.e 7.Vrie,�7o7
sign Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(chock a8 that apply)
New Construction❑ Existing Building❑ 1 Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ J Number of Units_ Other Cl Specify:
Brief Description of Proposed Work-,: cu S H H w
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 011lclal Use Only
Labor and Materials
I. Building S I. Building Permit Fee:f Indicate bow fee is Determined:
O Standard City/Town Application Fee
�. Electrical f ❑Total Project Cosl'(Item 6)a multiplier x
J. Plumbing S 2. Other Fen: f
4. Mechanical (IIVAC) f List:
5. Mechanical (Fire f
Suppression) Total All Fen:f
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S S�/ oo 13 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
S.1 Licensed Construction Supervisor(CSL)
I.icense Number Expiration I}JIC
Name of 00.-I lolder List CSL Type(see below)
lr I)escriphon
Address U Unrestricted u to 35.000 Cu.Ft.
R Restricted I412 family Dwellin
Signature M Masonry Only
RC Residential Roofing Coverin
feleplame ws Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or IIIC Registrant Name Registration Number
Address Expiration Date '
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. IS2.S ZSC(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..........O No...........0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 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.
Situation:of owner Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
X1 (/`E�`,( /'pJ S T—T- ,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
X behalf.
Print Name
S i!=r: l'fhvner uth Agent ` Date
Si under the sinas and nalties of 'u
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who him an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program), will aw 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 110.115. 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
). "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF S.U.E.Nvf
PUBLIC PROPERTY
D EPART NIENT
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HOMEOWNER LICENSE EXEMPTION
Please Priest
Date -
Job Location Ak7--e c.
Home Owner Address fk' /
Home Owner Telephone, q,2 7 c-P 5 C17�J7 X
Present Mailing Address <�g- 'g L e.e
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) wbo owns a parcel of land on which he/she resides or intends to reside, on
which tiers is, or is intended to be,a one or two family dwellin& 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 Of ciak 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 hetshe understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SALEM
' =j� `r` PUBLIC PROPRERTY
DEPARTMENT
�•�ilitla i 1.VI V. %1x. \i
III' •I'y '4;.141j I'\S: 9,8-'4:984o
Construction Debris Disposal Affidavit
(required lix all demolition and renovation work)
In accordance ill, the sixth edition ofthe State Building Code, 7S0 CNIR section I 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit ft is issued with the condition that the debris resultin.- from
this work shall be disposed of in a properly licensed waste disposal Facility as defined by MGL c
I11. S 150A.
The debris will be transported by:
vD r✓�/.v 5 -7-
Iname of hauler)_
he debris will be disposed of*in
��� ��Plf'r•Yr` 1�9�aL.
(name of laolity)
�l
(address ul't'acrlim
sign to • permit .gtplicanl
Q date _