1 GENEVA ST - BUILDING INSPECTION P Q The Commonwealth of Massachusetts Town of
►—j Board of Building Regulations and Standards AIMMOW
Massachusetts State Building Code, 780 CMR, 7"edition Budding Dept
y/ Building Permit Application To Construct, Repair, Renovate Or Demolish a
One. or rico-Fmndv Duelling Amiga
This Section For Oficial Use Only
Budding Permit Nu er: Date Applied:
Signature:
Budding Commissioner/Inspector of Buildings Due
SECTION 1:SITE INFORMATION
1.1 Propeefrr�ty, Address: 1.2 Assessors Map& Parcel Numbers
/ss�rn/
Ma Number Parcel Number
1.la Is this an accepted street'?yes no P
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(ft)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40.154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public O Private❑ Check if vesO
_ SECTION 2: PROPERTY OWNERSHIP'
2.1 Qwner'of Record:, /`^y V'1yt _�� ., jP.zj� 111
�- A /r`to� Addressfor Service:
(Print) vy�
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building❑ Owner-Occupied O Repairs(s) Alteration(s) ❑ Addition O
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other O Specify:
Brief Description of Proposed Work': "
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building S q s�, oo I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multi tier x
3 Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S Lise
S Mechanical I Fire S Total All Fees. S
Su ression
eta Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: S 5'0 " 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
r.
L.ccnse Number Expiration Date
Nytme of CSL-.1 plJer
List CSL Type lace beluw)
Address T' Descri tion
U Unrestricted u to 35,000 Cu. Ft.)
Signature R I Restricted 1&2 Family Dwellin
M Nslasonry Only
RCResidential Roofing Covering
Telephone WS Residential Window and Siding
7g SF Residential Solid Fuel Burning Appliance Installation
\` D Residential Demolition
.2 Registered Home Improvement Contractor(HIC) X
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.J 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 AfTidavit Attached? Yes.......... ❑ No...........
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
relativeejto work authorized by this building permit application.
Signature of Owner Date
SECTION 7b:OWNER' 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.. /� {y�
lj--ef-3g ��'/"7 1= L: P) fi t; rl'c -e—
Print Name
%.-fca �t.�oCu-wig /�l�l�cuf-cck, 1/0
(Signed
of Owner or Authorized Agent Date
Si ned under the pains and penalties of perru
NOTES:
I. AnOwner 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 nye(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 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 halfbaths
Type of heating system Number of decksi porches
Type of cooling system Enclosed Open
1. "Total Pro)ect Square Footage"may he substituted for 'Total Project Cost"
CITY OF SALLM
PUBLIC PRc)PRERTY
DEPARTLIENT
Iii v'.r.•t:. :.,: � I ,c •.'.r v= ,;1,,
Construction Debi-is Disposal Aflid.n it
` (required ti)r ;ill demolition and renovation work)
In accordance 111111 the sixth edition ufthc State Building Code, 780 CAIR section 111 5
Dcbris. and the provisions of.MGL c 40, S 54;
Building Permit H is issued with the condition that the debris resulting from
this work shall he disposed of in it properly licensed waste disposal lacility as defined by NIGL c
I11. S 150A.
The debris will be transported by:
J� I
1 na�r
I he debris will be disposed ofin
I.IImC
.,Jdn r. of Ian IIIVI
.ignjlu,c nI pc unit .ggilu dill
,I>I:
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
uouur�r�•• ,�
Vwwa t 30 Wwwu.T'CN SMENT 9 s ueK V AM4CMsern Q1V0
HOMEOWNER LICENSE EXEMPTION
Plmase prime
Date 8 3/
Job Locatift
Home Owner Address
Home Owner Telephone E,
Present Mailing Address z7 210
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
him who.does not possess a license.provided that the owner acts as supervisor.
DF,FINMON OF HOMEOWNER
Person(s) who oats 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 andlor.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
OfflcisL 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 and requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code