25 HORTON ST - BUILDING INSPECTION (3) The Commonwealth of Massachusetts iiSPECTI NMI O ICES
Board of Building Regulations and Standards SALEM
4 � Massachusetts State Building Code, 780 CMR .; e¢Aiulw40�Q
�°1k A tw
Building Permit Application To Construct, Repair, Renovate Or Demo is a
One-or Two-Family Dwelling. .
' This Section For Official Use Only
Building Permit Number: Date.Applied'
Building ORicial(Print Name). Signature=: '_ - Date
f SECTION I:SITE INFORMATION'
1.1 P pZ �ddriesUs2 S fi 1.1 Assessors Map dt Parcel Numbers
L I a Is this an accepted street?yes_ no Mop Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(Il)
F1.6uterSuppIj:(M.G.Lc.40,§54)
Setbacks(ft)
Front Yard - Side Yards Rear Yard -
- Provided Required Provided. Requited Provided
1.7 Flood Zane Information: 1.8 Sewage Disposal System:
Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if es❑ -
SECTIONZ;: PROPERTYOVVNERSHiP!
wnert of Record:
t,me(Print) - - City,State,ZIP -
2�- I+.r-h"A E4- TK--cn i- '234.3 /dam 4_6271 eC,2qE03
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction CIExisting Building❑ Owner•Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition
Demolition ❑ Accessory Bidg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work=:
SU t— na ti2i SYDu� ,nt lr&
SECTION 4: ESTIAIATED CONSTRUCTION COSTS
Item Estimated Costs: Oflicfal Use Only
Labor and Materials)
I Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical S ❑Total Project Cost.'(item 6)x multiplier x
3. Plumbing $ P Qther Fees: S
4.Mcchanical (FIVAC) S List:
5.\lechmtir I (Fire S Total All Fees:S
ressiun)
_ Cheek No. Check Amount: Cash Amount.
G. ' Nat Project Cost: S O ❑Paid in Full ❑Outstanding Balance Due:
(`I1�1\ 1. 'rp t-1 • O .
m tN.t
SECTION 5: CONSTRUCTION SERVICES
:..t.lf F t�p�s? IfiaSlr:l r•'t',r: ..
5.1 Construction Supervisor License(CSL)
rlt (fild Ift." License Number Expiration Date
N:une of CSL Holder
List CSL'fype(see below)
Type - - Description
No.and Street
U UnrestrictedBuildin u -to35,000cu. 11.
R Restricted I&2 Famil Dwellin
Cityfrown,State,ZIP M Masonry
RC Roolin Coverin
WS Window and Siding
SF Solid Fuel Burning Appliances
I I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
IIIC Company Name or HIC Registrant Name
No.aril Street Email address
City/Town, State ZIP Tele hone
SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G.IL e.02.$ 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 Isivance of the building permit.
Signed Affidavit Attached? Yes ..........❑ No...........❑
SECTION Tao OWNER AUTHORIZATION.TO BE.COMPLETED WHEN• "
OWNER'S AGENT OR CONTRA CTOItAPPLIES`FOR BUILDING.PERMIT
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application. ,Q1
V-T
Print Owner's Nance(Electronic Signature) Date
SECTION 711b:OWNEW ORAUTHORIZED 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:
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 nuf have access to the arbitration
—--
program or guaranty fund under M.G.L.c. IJ2A.Other important information on the HICYrogmm can be found�t
Fvwvv mass uov'oca Information on the Construction Supervisor License can be found at www.mass.eov,'
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 coma
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of healing system Number of decks/porches
'rypeofcoolingsystem Enclosed- Open
J. "Taal Project Square Footage"may be substituted for'"total Project Cost"
QT'Y OF SALEM, MASSAC HUSE M
BUILDING DEPARTMENT
120 WASHNGTON STREET,3" FLOOR
TEL. (978)745-9595
F
KIMBERLEYDRISCOLI, FAX(978)740-9846
MAYOR THows STRERRE
DIRECTOR OF PUBLICPROPERTY/BUILDING COAaUSSIONER
HOMEOWNER- LICENSE EXEMPTION
PLEASE PRINT:
Date 1 . 1 f-1 ) I to
Job Location as S+_ Soy
Home Owner Address S G ip
Present Mailing Address SLR
The current exemption of"Homeowners"was extended to include owner-occupied dwellings of two
Units or less and to allow such homeowners to engage an individual for hire that does not possess a
license, provided that the owner acts as supervisor.
DEFINITION 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 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 understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR