31 FORT AVE - BUILDING INSPECTION (2) A 1
The Commonwealth of Massachusetts
+— Board of Building Regulations and Standards CITY
� OF SALEM
Massachusetts State Building Code, 780 CMR, 7"'edition RevisedJwwury
Building Permit Application To Construct, Repair, Renovate Or Demolish a /• =oorr
r� One-or Two-Fumdv Dwelling
This Section For Official Use Only
Building Pertnil Num er: Date Applied:
Signature:
Building Commissioner/#wrleclor of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Addres 1.2 Assessors Map At Parcel Numbers
1.]a 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 11) Frontage(It) III
1.5 BuildingSetbacW(B)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provide)
1.6 Water Supply:(M.G.L c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal.System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑ P po y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownert of Record:
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building O Owner-Occupied 13 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.O Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work:
711 ,a,
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S Total All Fees: S
Suppression)
_ Check No. Check Amount: Cash Amount:
6. Total Project Cost: S 54 O O Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor ID
P 1
umber lispimlion Date
Name of C'SI.- I folder
Type(see below)
.Address escri lion
Unrestricted o 35,000 Cu.Ft.
Restricte 2 FamilyDwelling
Signature M• Onl
sidemial Roofin Covering
'I"clephone Residential Window and Siding
Residential Solid Fuel Burning Appliance Installation
Residential Demolition
5.2 Registered Home Improvement Con or(HIC)
IiIC Company Name or II1C Regist ame Registration Number
Address
Expiration Dale
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 ..........O No...........O
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
' e to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I, 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.
(DIN h 5 L Q Etr ) EL
Print Name
Signature of Owner or Autho d Agent Date
(Signed under the pains and Penalties of 'u
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 go 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 780 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
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
1 V/
1'dC MRl "Illr. 11
-/SH •,I:'\!C Y7t;JS'rMJh I..:1'r':
construction 11Debris I)IlP•nualivawud vit
(ruquiIn lccun!uxe with the sixth edition of the State building Code, 780 CMR section 11 I.S.
Debris, and the provisions of MGL c 40, 5 54; molting
c
is issued with the condition that the debris front
Ouilding Permit 0 l licensed waste disposal facility as defined by
This work shall be disposed of in a proper Y
111. 5 150A.
The
i—�-14
debrisywill be transported by:
Ce c,,arm of hauler
The debris will be disposed of in
(nurrle ul un lty
I adJrtea ul'I'x llilyl
z At
.I�nalure nlL/,ermit applit:aM
,late
CITY OF S.XLYENf
PUBLIC PROPERTY
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HOMEOWNER LICENSE EXE.MMOV
Pkaw tri�t
Dam
Job Locatim
Home Owner Address 31 Y-0 A t/t=
Home Owner Telephone
Pmsent Mailing Address
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
hire who does not possess a Hcensa6 provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Persons) who owns a parcel of land on which be/she resider 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
-mill comply with said procedures and requirements,
HOMEOWNERS SiGNArm r(��
APPROVAL OF BUILDING [NSPECTOR I!!L",,,
See other side for state code