2 FOSTER CT - BUILDING INSPECTION Gcl � ee)e(e
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I l The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
r Massachusetts State Building Code,780 CMR SALRevised tLEMar 20/l
Building Permit Application To Construct, Repair, Renovate Or Demoli a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied: ��••
u�+e
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Propertc Sty)ddress: 1.2 Assessors Map& Parcel mbers
�� N2 Cnct/c't
1.[a Is this an accepted street?yes l'no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(tt)
1.5 Building Setbacks(ft) J
Front Yard Side Yards Rear Yard
Required Provided Rcquimd 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 yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: 1i
MA/I✓ AFitt 4 _ (t.M lJ IlGeIFz f 6� /� i Sd&en MG Cr/rt�0
Name( mt�c/y City State,ZIP 1
a J /,[/ej1 C f itjfm7_ /.. S f..2t f m- A,A.)E2 otInc_ �
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': c er
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:
�. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
C) List:
/,
4. Mechanical (HVA $ L List: / / r i',
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: S 5000 ,v p ❑Paid in Full ❑Outstanding Balance Due:
1( , QC� row � f -
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name ofCSL Holder
List CSL Type(see below)
No. and Street Type Description
U Unrestricted(Buildings up to 35.000 cu. It.)
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
"fele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
Ii1C 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 behalfrin all matters relative to work authorized by this building permit application.
Mct y Covefuar
Print Owner's Name(Electronic Signature) Date
SECTION 7b: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
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 can be found at
www.mass.eov/ooa Information on the Construction Supervisor License can be found at ww-w.mass.gov/dns
-7. 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"
CITY OF sm.E.Nt, LK-uS.kcHUSETI'S
• OCIIDLVG DEPARTMENT
' 120 WASHLNGTON STREET, 3i0 FLOOR
TM (978) 745-959S
FAX(978) 740-9846
KiSBERLEY DRISCOLL
MAYOR T Het.% s ST.PmRn
DIRECTOR OF PCBL c PROPERTY/9CMDLNG COMWISSIONER
Construction Debris Disposal Affidavit
(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 c 40, S 54;
Building Permit At 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 MGL c
111, S 150A.
The debris will be transported by:
(n of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signs re of permit applicant
date
d.bnvtfd.w
CITY OF S.u.E.NI
PUBLIC PROPERTY
DEPARTMENT
KJfOWC.r.ryya
wroa taovAo.w."fnaar•spun VnoMowssrnotre
HOMEOWNER LICENSE EXEMPTION
Pleass "I
Date E-7-11
Job Location Co het C�
Home Owner Address a e f C
Home Ownm Telephone a7 YY- S V,2 6
Pres"Mailing Address 2 e 5 f a2
The current exemption of"Homeowner"wss extended to include owner-occupied
dwellings ottwe Units or less and to allow such bomeowner to engage an individual for
hire who.does not possess a Uceo^provided that the owner acts as suparviow.
DFFaIrMN OF HOMEOWNER
Person(s)wbe owns a parcel of land on which he/she resides or Intends to reside,on
which then is, or is intended to be6 a one or two &m ft dweWn`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
' meowner'shall submit to the Building OQlcial,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"catiHes that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and rregwrjtrots.
HOMEOWNERS SIGNATL'RB
APPROVAL Of SUILDENG DiSPECrOR
See other side for state code
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