13 FORT AVE - BUILDING INSPECTION (2) g �! The Commonwealth of Massachusetts
t� Board of Building Regulations and Standards CITY OF
� Massachusetts State Building Code, 730 CtMR SdMar 71 Revised h(nr 201/
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Divelling
This Section For Official Use Only. '
Building Permit Number: 'e A plied
wilding Official(Print Name) n .,re - Date
SECTION L SITE 7t FO r WTION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
this✓-1 — _
1.1 a a Is this an accecepted streetq yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.01 c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal Cl On site disposal system ❑
Check if yes❑
SECTION 2:, PROPERTY ONVNERSHIPL
2.1 Ownert of Record: � � O t U
�I e LIME Sr M , N"y��
q 1
Noma(Print) Ciry,State,ZIP
13 ►-ova Awe 49$ '13a 324Z
t No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORle' check all.that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
Lj
SECTION4: ESTIMATED.CONSTRUCTION COSTS""
Estimated Costs:
Item Official Use Only
Labor and N(aterials
1. Building ; 1..Building Permit Fee S - Indicate how fee is determined:
�. Electricil $ ❑Standa rd..Cityrrown Application Fe&
❑'rotal Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
t. Mechanical (IIVAQ $ List:
5. ;Mechanical (Firs $
Su � rossiun) _ lbtal All Fees: .$_
�/ — -- Check No. _Clink Amount: _Gash ,\mount-.
"//(\ r, -1'10ta1 Project Cost: 3 0 Paid in Pull ClOutstandim, Ilul.ulce 1)11a:
SECTION 5: coVS'rRUCrION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Gepirttiun Date
Name orCSL Holder List CSL Type(see below)
Type Description
No. and Street
U Unrestricted DuilJin s u to 3i,000 cu. R.
R Restricted 1&2 Funil Dwvellin
City/Town, State, ZIP NI k0asonr
RC Roofm Coverin
lvs Window and Sidi—,
SF Solid Fuel Burning Appliances
[ Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(IIIC)
H[C Registration Number Expiration Date
IIIC Company Name or 1-IIC Registrant Name
No. and Street Email address
City/Town, State, ZIP 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 DE 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.
Print Owner's Name(Electronic Signature) Date
SECTION 7h: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
conned in this application is true and accurate to the best of my knowledge and understanding,
e �A�cllt
' ( 23 �Print Owncr's or Authus Nume(Electrunic Signature) Date
NOTES:
I. :\n Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(nut registered in the Home Improvement Contractor(H[C) Program), will not have access to the arbitration
program or guaranty fund under LM.G.L. c. 142A. Other important information on the HIC Program can be founts at
wwwv.nuus, uvhrCu Information on the Construction Supervisor License can be found at ww•w.mas;.,2u3�'dp_;
2. When substantial work is planned,provide the information below:
total floor area(sq. (t.) (including garage, finished basement/attics,decks or porch)
Gros; living area(ski. d.l habitable room count _
Number or fit eplaces_----------- Number of bedrooms
Number Of bathroom; Number of halt baths _--
I'cpc of hc.uing syslcnt
I}peot"Cool ill" ;y:tcm _ finclosed _,— - — Opcn ---_--
1. I',tltll'r.,j�it �yuuo1:1 nt,1 111.1vll lfv ' I �[dPIoject ('o;t" ..
CITY OF S.U.0vi
PUBLIC PROPERTY
DEPARTMENT
w,r�st a.eaaxL
w.a
t b vhw�,�+o„swear�s.�„s.V��saow ern 01 fro
HOMEOWNER LICLNS6 E.Xj.mpTI0►V
Please "I
Date 23 z,i l
lob Face _gax2r- 3
Home Owner Address , -x A,.k
Home Owes Telephone q l is 1430 • 3 z y z
PrestsnlM�gAdthteas sir•-�
no current exemption of"Homeownme"wee extended to include ow tw oesupied
dwellings ottwo Units or lw and to anew such homeownare to engage an individual for
hire who.does two poeaeae a If AU46 provided that the owner acts ae supervisor,
DEFINITION OF HopaoWNEA
person(s) who owns a psted otLnd on which hs✓she restdee or intersds to resider on
which there is; or is intended to bo, a one or two thmily dweWng, attached or detached
struotnres accessory to such use and/or farm strstcturee, A person who comtructs more
than one home in a two yes period shad tot bo considered a homeowner. Such
"homeowner"shall submit to the Building OQlciA on a form acceptable to the Building
Official, that hdshe be raponsibb for all such work performed under the Building
Permit
The undersigned "homeowner"assumes responsibility far compliance with the State
Building Code and other applicable by- and regulaations.
The undenigned ,homeownam certifies that hdshe undentands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
,vill comply with said procedures equirements.
HOMEOWNERSSIGNArLI" (G?ne
.lPPROVAL OF 3U/LD/VG LVSPECI'0,R .
See other lids far state cols