11 JACKSON ST - BPA B-2010-165 Q The Commonwealth of Massachusetts Town of
I Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 7"edition Building
�11\1a� Building Permit Application To Construct, Repair, Renovate Or Demolish a
WWW One- or Ttco-Fun 1. Du'elling
Thi S cutn F r Official Use Onl
Building Permit Num c Date Applied:
� a
Signature:
Building ornmisvoned Inspect f Bud ings Date
SECTION 1: SITE INFORMATION
1.1 ronnerty Address. SYeef 1.2 Assessors Map& Parcel Numbers
�yGc�ym I
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 fl) Frontage(R)
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,S54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system O
Public O Private❑ Check if esO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner�i qf Reeord: ^� �` , J —.
�ln ! rya _N C GKd nl
Name(Print) n- Ad es for ervme:
LA C�v 4
Signature - Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied 0 1 Repairs(s) ❑ Alteration(s) O Addition O
Demolition O Accessory Bldg. 0 Number of Units_ Other O Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building f I. Building Permit Fee: $ Indicate now fee is determined:
❑Standard To
Application Fee
2 Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3 Plumbing S 2. Other Fees: $
cvk
4. Mechanical (HVAC) S List:
5 Mechanical (Fire S Total All Fees: S
suppression
�y Check No. _Check Amount: Cash Amount:
6. Tatal Project Cost S 1 ❑ Paid in Full O Outstanding Balance Due:
rSECTIONS: CONSTRUCTION SERVICES
L
ruction Supervisor(CSL)
L,censc Number Expuation Date
Ltit CSLT
YDe lace Ixlow)Type I Description
U I Unrestricted tup to 35,000 Cu. Ft.)
Signature R Restricted Ik2 FamilyDwellin
M 1 Masonry Only
RC I Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance 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.f 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...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S GENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1• r�i.. 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.
Signature of Owner 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 nalties ofperjury)
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 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 I IO.R6 and I IO.RS, respectively.
2. When substantial work is planned,provide the information below:
Total fl rs 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 he .uhstifuled for 'Total Project Cost'
CITY OF S.U.E.Nf
PUBLIC PROPERTY
DEPART, MNT
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rM 9711-70-ss+s•r•..r 975-74a9a4
HOMEOWNER LICENSE EXEMPTION
Mass "I
Date a v9
7�
Job Location
Home Owner Address
Home Owner Telephone a a 3 O
Praaot Mailing Address Gli
The current exemption of"Homeowners"was extended to include owns-occupied
dwellings of two Units or less and to allow such homeowners to engage an individual for
hire who.does not possess a lieens%provided that the owner acts as supervisor.
DEFIMMON OF HOMEOWNER
Person(s) who owns a pareei 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 dwellin& 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 ail 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 a
APPROVAL OF BUILDING INNSPECTOR
See other side for state code