22 FORRESTER ST - BUILDING INSPECTION (2) The Coin mom weal th of N4assachusetts
Board of Building Regulations and Standards CCCY OF
,j Massachusetts State Building Code, 780 CLI SALE v(
Revised Mar 2011
Building Permit Application To Construct, Repair, novate r Dem lish a
One-or Two-Family Dnof ling
This Section For Official Use Only. `
Building Permit Number:, 14
Ste Applied,
^Building Official(Print Name) Date
SECTION L SITE b INIATION
J Fz
ert��Ad ess:�j �1 etM/ Vol 2 sessors Map& Parcel Numbers
t V P JT in
this an accepted street?yes_ no Map Number Parcel Number
oning Information: 1.4 Property Dimensions:
District Proposed Use Lot Area(sq ft) Frontage(ft)
ilding 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: LS Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2:; PROPERTV OWNERSIlIW
2.1 Ownert of Record:
. IRA 0-fi(- v (At TlP
Name(Print) ,.�--�� try, Ste,ZIP
VFDescription
V Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WOR10(check all that apply) .
❑ Existing Building❑ wner•Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
of Proposed Work:
ce IF 16 ea
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Labor and Official Use Only-
I, Building $ I. Building Permit Fee-.3 ` Indicate how fee is determined:
2. Electrical 5 ❑Standard._Cityaown Application Fee
❑'focal Project Cost(Item 6)x multiplier e
J. Plumbing i 2. Other Fees: .3
1. ,Mechanical (IIVAC) S List:_
i. Mechanical (Piro $ -
J_nP tressioll) _ -__ l•otal All Fees:3-
eJa Chxk i lo. __Check Amount: _CaAi ,\umunt:
n Cu Ctl Project Co it ) ❑ Paid in Pllll 0 outstanilim" li;il:uncc Ihw:
SECTION 5: CONSTRUCTION SERVICES
5.1 Constructiml Supervisor License (CSL)
License Number E.epiratiou Date
N;une ofCSL I folder List CSL type(sea below)
type Description
No. and Street
U Unrestricted(Buildings up to 33,000 w. tt.
R Restricted 1&:2 Family Dwcllin
Cityfrown,State, ZIP M %lasonr
RC Rootin Coverin
WS Window and Sidio
SF Solid Fuel Burning Appliances
I Insulation -
I'ele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
FI[C Registration Number Expiration Date
I IIC Company Name or IiIC Registrnnt Name
No.and Street Email address
City/Town, State, ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 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...........Cl
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.
Print Owner's Name(Electronic Signature) Date
SECTION 7h: OWNER' OR AUTHORIZED AGENT DECLARATION
By enterin ry name below, I hereby atte t under the pains and penalties of perjury that all of the information
contai d in this ap ''ati s tr a curate to the best of my knowledge and understanding.
I`rint Owner's or A rired:\;ent's Name(Eleeronic Signattiru) Data
VOTES:
I. An Owner who obtains a building permit to do hisiher own work,or an owner who hires an unregistered contractor
(not registered in the Hone Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty find under t\LG.L. C. 142A. Other important information on the HIC Program can be found at
��ww m:u+.euvioc:t Information on the Construction Supervisor License can be found at din
? WI en substantial work is planned,provide the information below:
Total tloor area(,y. It.) ___ _(including garage, finished basetnent/attics, decks or porch)
rroi; livim�Are,'(iyl R.) --_ — Habitable room count --
Number of tircphiccs_ .—_ Number of bedrooms
---------- —
NumberotIm[hm„ms Number ofh.ulEbalhs ---------__.__--
- - ---
I'�pa of ha.tting iyaant Niunbcr of duck„pore uci
----
— [inclosed pen
� t. ' fotal in.ty lie ;ub;hhd.dL,r"['.-r.illYnjsll'i"t
}
CITY OF S.U-E%f
PUBLIC PROPERTY
DEPARn, ,ENT
u.u.aaav e.au�u
w.ve ]e v�vw-tesr snaa. lKna Vwfuow scrrs of tl'0
rta,9"2.71175/!
HOMEOWNER LICLNSE EXE.MrrlO,V
Pleaw Islet ,
DAN�
lob Loeadw (-C Sew, mil. O 11�L6//
Home Owner Address b t/
HomsOwnaTelepbooe — S—o3a-S
Pressed Milling Address f--p _
no curtest exemption of"Homeowner"was extended to include ownwoeeupied
dwellings of two Units or tea and to allow.such homeowner to eogep an individual for
him who does not possess a Heenso provided that the owner acts so supervisor:
DFYIN ON OF HOMEOWNER
Pawn(s) who owns a parcel of lead on which he/she resides or intends to nwide,on
which them iy or is intended to bo, a ouster my Atmily dwelling, attached or detached
structures accessory to such use and/or(arm structures. A person who conatnute more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner shall submit to the Building OQlciak on a roan acceptable to the Building
0tfcial, 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 undenigted "homeowner certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requi ents and th he/she
will comply with said procedures and r5luiremen
H0MEOWNERS SIGNATURE
.APPROVAL OF BUILDING OYSPECTOR
See other side for state cods
I
4 �
L
CITY OF S.UZ I, 1SS;ICHUSETTS
�s .
Bl:ttDL\G DEP.1R'ITIEVT
120 C(/.{�HLNGTON STREET V, FLOOR
TEL. (978) 745-9595
iCIJtBE,4LEY DRtISCOLL FVC(978) 7•W-9346
T110mu ST.PtERRs
DIRECTOR OF PUBLIC PROPERTY/SUIL.DLNG CMNISSIONER
Construction Debris Disposal AffZdavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section l 11.5
Debris, and the provisions of NIM c 40, S 54;
Building Permit k 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 s%,IGL c
111, S I50A.
The debris will be transported by:
V r Qf
(namc ul'hauler)
'['he debris will be disposed of in :
-- (nama at'tacitily)
(address of tacilicy)
4sig[Wu afpermitappticant
dace
` i