4 HOLLY ST - BUILDING INSPECTION (2) ` The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
1•tty j Massachusetts State Building Code, 780 CMR, 7"edition OF SALF.M
RevisedJunuury
^�J Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 20011
Y \ One-or Two-Family Dwelling
This Section For Official Use Only
FBuilding Permit Nu ber: Date Applied: v
ure:
Building Commissioner/Inspector of Buildings Date
SECTION I: SITE INFORMATION
trily Address: 1.2 Assessors Map& Parcel Numbers
OU�_ s-V
this an accepted street?yes no Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(It)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
"(Pfint
ccd• `/ �L
`1 ��L .XAdd�dS� e TelephoneTION 3: DESCRIPTION OF PROPOSED WORK"(check all that apply)
Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work-, o
u2jksi
cy(-
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OMCISI Use Only
Labor and Materials
I. Building S I. Building Permit Fee:S Indicate how lee 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 (IIVAC) $ List:
5. Mechanical (Fire S
Su ression Total All fees:S
Check No. Check Amount: Cash Amount:
6. Total Protect Cost: S /aJE3 Paid in Full 13 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
fiN�=.e
icensed Construction Supervisor(CSL)
I.iccnse Number Expiration Date
ol'C'51.•I IalJer List C'SL Type(see below)
T- Description
Address U llnresuicted u to 33.000 Cu. Ft.
R Restricted IR2 FamilyUwellin
Signuturc M M Only
RC Residential Roulin Coverin
I'.I.PN WS Residential Window and Sidin
SF Residential Solid Fuel Bumin A liance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
IIIC Company Name or HIC Registrant Name Registration Number
Address Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.1 2SC(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 .......... 0 No...........0
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.
Si ure of Owner Date
ION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
'�z' ,as Owner or Authorized Agent hereby declare
that the statements and n rrnation on the foregoing application are true and accurate,to the best of my knowledge and
behalf r--
G
Print Name
Signature of Owner or Authorized Agent Date
Si ed under the pains and penalties of 'u
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 ngf 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 1 I O.R6 and I IO.RS,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"maybe substituted for"Total Project Cost"
CITY OF S.ULE.Ni
PUBLIC PROPERTY
DEPARTNMENT
MArar 130 ryxyUNGTpN 1TUM•IMAK MwriACHLMM 019-0
T4i 97L744S"• F.%c 978.744904
HOMEOWNER LICENSE EXEIMMON
Flew "It
Date e I.i !O ),/
Job Location
Horne Owner Address L fi
Home Owns Telephone U O X
Presaot Mailing Addrea@ Al
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 powas a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she reside@ or intends to reside, on
which tiers 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
Ofticial. 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 r men uire
HOMEOWNERS SIGN RE ATU ,L-
,APPROVAL OF BUMMING INSPECTOR
See other side for state code
i
.' + : CITY OF SALEM
y PUBLIC PROPRERTY
DEPARTMENT
12:
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 Ch1R section 1 1 1.5
Debris, and the provisions of NlGL e 40, S 54;
Building Permit it is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11. S 150A.
The debris will he transported by:
(name ot'hauler)
I he debris will be disposed of in
(name ot'I'acinty) - -
(mlares.s A IacJily)
X.
! ,ire o nn f Pe applicant
_T— dale