27 1-2 FOSTER ST - BUILDING INSPECTION z, Phe Commonwealth of Massachusetts
o Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 71h edition OF SALEM
Revised Junuury
Building Permit Application To Construct,Repair, Renovate Or Demolish a '008
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Numbe • Date Applied:
Signature: e3 , (2 h ( 0
Buildi ummt o Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: p 1.2 Assessors Map& Parcel Numbers
�Z-f�� :SC I,( O IA/I
1.I 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(11)
1.5 Building Setbacks(B)
From 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:
Public❑ Private❑ Zone: — Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.l Owner'of Record:
tJ,,,r�r., P4,r�na> a—)'iz -Fr x kr v cS�
N mey (Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKr(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ f Repairs(!) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Olilcial Use Onl
Labor and Materials y
I. Building S 1. Building Permit Fee:S Indicate how tee is determined:
2. Electrical S ❑Standard Cityrrown Application Fee
❑Total Project Cost'(Item 6)x multiplier x
. Plumbing S 2. Other Fees: S C2
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
6.Total Project Cost: ISCheck No. Check Amount: Cash Amount:
� �) 0Paid in Full ❑Outstanding Balance Due:
f
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name ol'CSL-I lulder List CSL"type(see below)
t Description
Address U llnrestricteJ up to 35.000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC Residential Routin Coverin
Tekphona WS Residenial Window and Sidin
SF Residential Solid Fuel RunningAppliance Installation
D Residential Demolition
5.2 Registered Home 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. 152.1 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
NER'S AGE OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
authorize to act on my behalf,in all matters
re rive to work authorized by this building permit application.
Si tore ofOw Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1 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
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury)
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 MoJ 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 I IO.R6 and I 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 halfibaths
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 SALE.%vi
PUBLIC PROPERTY
DEPARn. iENT
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HOMEOWNER LICENSE EXEMPTION
Plow prime
Date 7--�h 2 /y
Job Location I�i-ea-
Home Owner Address 7,c vv.,c
Horne Owner Telephone 0ZY.
Present Mailing Address r r .2-7,t 2 ff ,C�
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or lesa and to allow such homeowners to engage an individual for
hire who does not possess a licensee,provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Person(s) 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 wont 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 procedur and requ• emrnta
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING DiSPECTOR
See other side for state code
CITY OF SALEM
r PUBLIC PROPRERTY
3�Jai
DEPARTMENT
sl'.lau�o:,ivSrxrrr •SA I M. %l.t;"l
I'FI:'Atl-N 9W5 I\%:')7tl•+�S'Itl*
Construction Debris Disposal Affidavit
(required I-ur 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 !f ' _ is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I 11, S 150A.
The debris/ will be transported by:
—
Inarne of hauler)
The debris will be disposed of in
>. faculty)
(lldltrCSA UI 1'al lhly)
;isnature of permit applicant
date