16 FORT AVE - BUILDING INSPECTION L; 1
The Commonwealth of Massachusetts
I7OR
Board of Building Regulations and Standards MUNI('IP:V.I'I'1'
\� Massachusetts State Building Code. 780 CMR. 7'h edition USE
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Juuuw%
One- or Two-Fmnily Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied: �J
Signature:
Building C'o missioner/ Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address:
�� �V 6 1.2 Assessors Map & Parcel Numbers
L la Is this an accepted street'?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq it) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.1.c.40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? in
Public❑ Private❑ Check if yes❑ Municipal ❑ On site disposal syste ❑
SECTION 2: PROPERTY OWNERSHIP[
2.1 Owner[of Record:J (1f'/6 (4 r /� p,6 1-�vG
Na Print) Address for Service:
q7R J � 5-r5/s3
Sign re Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteretion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Wf 'o " z— O�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $
❑Total Project Cost (Item 6) x multiplier x
3. Plumbing $ 2. Other Fees: $
O4. Mechanical (HVAC) $ List:
1 5. Mechanical (Fire $ Total All Fees: $
Suppression)
Check No. Check Amount. Cash Amoune
6. Total Project Cost: $ 500a 0 Paid in Full ❑ Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES r.
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL- Holder List CSL Ty
pe(see below)
Address Type Description
U Unrestricted(up to 35,000 Cu. Ft.)
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Horne Improvement Contractor(HIC)
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........... O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, +l , 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.
Signature of Owner Date
SECTIONS 7bb:�OpWNEW OR AUTHORIZED AGENT DECLARATION
�JS,( � 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
behalf.
Print Name 03
29
Signature f Owner o uthorize ge Date ,(.
(Signed un er the ai s and penalties of perjury)
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 110.116 and 1 IO.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 XLEM
PUBLIC PROPERTY
DEPARTMENT
K11fYc� sv r>.w-v
VAraa 120 WA9aW WN STUNT 0 SMAK VASMAG SEM 01970
Ma-978-70-9S"• FAx 97a.74&96 6
HOMEOWNER LICENSE EXEMPTION
Please Print
Date
Job Location G /=G°�r/- l/,
Home Owner Address / GOCUp6 S G�+-1
Home Owner Telephone 1z - 3
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.
DEFINMON 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures d requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INS CTOR
See other side for state code
CITY OF SALEM
,31i• i
PUBLIC PROPRERTY
DEPARTMENT
\t vi 1K 12C WA.ij G:Jv STREET • SAL!M. 51AtiAC U I611i:191C
'Cr1:979-745i9595 • FAx:979-74C-9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CNIR section 111.5
Debris, and the provisions ofLIGL c 40, 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 disposal facility as defined by %1GL c
111. S 150A.
The debris will be transported by:
(uame of hauler)
l'he debris will be disposed of in
1 name ul'lati6ty)
, • ::.turn i,;gin;-.0 aha
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