16 GOODELL ST - BUILDING INSPECTION The Commonwealth of Nassachusetts
OF
Board of Building Regulations and Standards CITY M
�
Massachusetts State Building Code, 780 CNIR SdMar, I Revised Mar 2011
Building i'ermit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling n
This Section For Official Use Only
Building Permit Number: 'Date Appliad,
wilding Official(Print Name) ; 'Signature Date
SECTION I: SITE INFORIVIATI
1.1 Property Addre s s: 1.2 Assessors Map & Parcel Numbers
00 /� f
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 ft) Frontage(fit)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c. 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public El Private ❑ Municipal if yeyes[] unicipal ❑ On site disposal system ❑
SECTION2:' PROPERT 'OWNEIR/SHIP'
2 Ownert of Record:
.SV,?1c1en t Elrurhe
N (Print) City, ate,ZIP
/6 Gvoelell Sf• zl�
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply).
New Construction ❑ Existing Building ❑ 1 Ow r-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Descri tion((`ofPro osed/ /Vork2 e $
SECTION 4: ESTIMA. TED CONSTRUCTION COSTS
Estimated Costs.
Item Official Use Only
Labor and Materials
ae w e ee i
I. Building 1 Bulling Permit $ induc t ho fe is d t tm ned:
❑ Standard CityKrown Application Fee
2. Electrical $ - -
- ❑Total Project Cost' (ltem.6).r multiplier.' x
3. Plumbing $ 2. Other Fees: $
1. Mechanical (IIVAC) S List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
� Check No. Check Amount: Cash Amount:
6 Total Project Cult: S a> ❑ Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number E.eptration Date
Name of CSL holder ,
List CSL Type(see below)
No. and Street Type -, - Description
U Unrestricted(Buildings up to 35,000 cu. 11.)
R Restricted 1&2 Family Dwellin
City/Town,State,ZIP IVI h4asonr
RC Roofing Coverin
_ WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
relz hone Email address D Demolition
5.2 Registered Home Improvement Contractor(111C)
HIC Registration Number Expiration Date
HIC 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...........
11
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 relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering m me below, I hereby attest under the pains and penalties of perjury that all of the information
containe 'n t is application is true and accurate to the best of my knowledge and understanding.
�a-iy-�z
Print Owner s or Authorized Agent's Name(Electronic Signature) Date
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 not have access to the arbitration
program or guaranty fund under M.G.L. c. l42A. Other important information on the I11C Program can be found at
w-ww.mass,,,ov%oca Information on the Construction Supervisor License can be found at www.mas ._o�'idyw
2. 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 — _—_ —
Nunnbcr of bathroanns Number of malt/baths --
r}pe or heating syslenn _ -- Number of decks/ porches - ___--
1'ype of cooling systenn__—_------ 1inclosed----__----- —_Open
J. `I olal I'roject Square Footage" may be sub_titut,d t;)r';T,ltll Proleet Cost''-- -- -- --
CITY OF S.UY.Nf
PUBLIC PROPERTY
DEPARTMENT
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HOMEOWNER LICENSE EXEMPTIOIN
Ptew Pritat
Dam 12-/Y_lz-
lobLoeatiosa
Home Owner Address 16 6-ood e 4 e..t '�4(A
Home Owner Telephone 7 79'—;7 Yy-Z/7G
Presmt Mailing Address
The current exemption of"Homeowners^was extended to include ownw-occupied
dwellings of two Units or leas and to allow such homeowners to engage m individual for
hire who does not possess a license provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Person(s) who owns a paeei 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
"lwmeownes"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 reguladons.
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 SIGNAMW � C/ L
APPROVAL OF BUILDING NSPECTOR
See other side for state code