The URL can be used to link to this page

14 FORT AVE - BUILDING INSPECTION �Slo D--- The Commonwealth of Massachusetts t Board of Building Regulations and Standards RECEIVED TY OF LEM Massachusetts State Building Code, 780 WECTIONL- SE v1C�AM Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Demoli h aQ � t 3 One-or Two-Family Dwelling His J& 2 This Section For Official Use Only (1 Building Permit Number: - D e Applied: . t Building Official-(Print Name) Signature ^ SECTION 1:SITE INFORMATION , t�J J 1.1 ro a ddress: n 1.2 Assessors Map&Parcel Numbers �e �� YOffi AV"� 1 1.1 a Is this an accepted street?yes no Map Number Parcel Number F Zoning Information: 1.4 Property Dimensions: ning District Proposed Use Lot Area(sq ft) Frontage(ft) 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: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yesO SECTION 2: .PROPERTY OWNERSIIIP' 2.1 Owner'of Record: Name(Print) City,State,ZIP No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK (check all that apply) - New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ I Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify: Brief Descrirtion of Proposed Work': P e ql fiU,$) i- I-7Lo i l n F o F6RI C4,,y re,, 1-1,11WVle n ( ITC SECTION 4:ESTIMATED CONSTRUCTi011t COSTS Estimated Costs: Item Official Use Only (Labor and Materials 1.Building $ 1. Bm7ding Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:.$ - Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 8 080 13 paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) p License Number Expiration Date Name of CSL Holder List CSL Type(see below) No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft. R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date HIC Company Name or HIC 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 BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,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 7b: OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby a est under th s and penalties of perjury that all of the information contained in this ap lication is true and curate to the t my knowledge and understanding. UN--, R -oqh Print Owner's or Authorized Agent's Name Signature) Date NOTES: I. 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 can be found at wvvnv.mass."ovloca Information on the Construction Supervisor License can be found at www.mass.>oc, v/dns 2. When substantial work is planned,provide the information below: Total floor 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" OTY OF SALEM, MASSACHUSETTS 3 . ( BUILDING DEPARTMENT` 120 WASHINGTONSTREET,3"FLOOR TEL. (978)745-9595 KIMBERLEYDRISCOLL FAX(978)740-9846 MAYOR THOMAS STTIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: I Date Job Location Home Owner Address I L( ro f LC 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 that does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Persons)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 understand the City of Salem Building Department minimum inspection procedures and requirements and that he/she will comply with such procedures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING INSPECTOR NOTES,' r RE _ .. �. C E1 PT DATEuti Zr No �42<7° ,5'8 n v Xf- y c RECEIVED'FROM A�ysDDR�ESS c0 �` 1 1 y�AR It~Y• 3✓ r © �4 � h` N �4ti lMi % S�(If�� AMT OF v Sao m 'r E � �v�:Y. v,_ n .,....r.::. ..�.tir.�� ...a.,r�`1'".f`.�A`✓�5`�� ®zoi�niruct yy 07 Y OF SALEA MASSAC RUSE M SHINGTO STREET, NT 3RD 120 WASHINGI'ONSTREETj 3'�FiooR IkL(978)745-9595 KIMERLEYDRISCOLL FAX(978)740-9846 MAYOR THCMAS ST131EM DIRECTOR OF PUBLiCPROPERTY/BLIIlAINGCOM gSSIOMR Construction Debris Disp osal A idavit (required for 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 c40, S 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste deposit facility as defined by MGL c 111, S 150A. The debris will be transported by: Nd J-c C6,/11M (name of hauler) The debris will be disposed of in: oy (name of facility) (address of facility) Signature of applicant �1lag �S Date