2 JACKSON TER - BUILDING INSPECTION '1 The Commonwealth of Massachusetts
Board ol'Buihling Regulations and Standards CITY
Massachusetts State Building Code. 780 C'MR. 7"edition lIF dJun:M
Rrvu�rd Jmrru.rr
1 Building Permit Application To Construct. Repair, Renovate Or Demolish a
One-or rwo-Family Dwelling
This Section For Official Use Only
Building Permit Number: Dale Applied: �/ U
Signature.
Building Commissioner/Inspector of Buildings Date
SECTION I: SITE INFORMATION
v'Eit
1.2 Assessors Map& Parcel Numbers
is an acce ted street?yes no Map Number Parcel Number
ng Information: 1.4 Property Dimensions:
strict Proposed Use Lot Ain(sq Il) Frontage(11)
ing Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?
Public❑ Private❑ — Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
L I Owner'of Record:
Nam (Print) Address Inc Service:
g 28'.
Signature Telephone
SECTION 3. DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ 1 Existing Building Mrf Owner-Occupied ❑ 1 Repairs(s) PJ Alleration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed W rk':
n��"
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 011lelal Use Only
Labor and Materials
1. Building S p��� 1. Building Permit Fee:S Indicate how fee is determined:
1. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost(Item 6)x multiplier x
I Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List_
�.
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No. _Check Amount: Cash Amount:
r/ 6. Total Protect Cost: S (' W 13 Paid in Full 0 Outstanding Balance Due:
, r
SECTION 5: CONSTRUCTION SERVICES
5.I Licensed Construction Supervisor 1CSL)
Liccme Number Expintion Date
Name of CSI.- I lulder Lisa CSL Type(sce below)
f Ilescri ion
Address U Unrestricted u to 35.0W Cu.Ft.
R Restricted IA2 FamilyDwelling
Signature - M M Only
RC Residential RoutingCoverin
fcicptene WS Residential Window and Siding
SF Residential Solid Fuel Bumin Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or f IIC Registrant Name Registration Number
Address Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. ISL / 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 ..........O No...........O
SECTION?a: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 authori by this ilding permit application.
Si ure of Owner Dote
SECTI b: OWNEW OR AUTHORIZED AGENT DECLARATION
1 ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are We and accurate,to the best of my knowledge and
behalf.
Print Nome
Signature of(honer or Authorized Agent Date
7An
the ains and penalties of 'u
NOTES:
er who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
tered in the Home Improvement Contractor(HIC)Program),will Ug have access to the arbitration
or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
tion Supervisor Licensing(CSL)can be found in 7R0 CMR Regulations 110.R6 and I I0.R5, respectively.
bstantial work is planned,provide the information below:rea(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 healing system Number of decks/porches
Type of cooling system Enclosed Open
3. 'Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF &U.Em
PUBLIC PROPERTY
DEPARTMENT
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HOMEOWNER LICENSE EXEMPTION
Pies" "t
Job Location G Son /Q
Home Owner Address
Home Owner Telephone �/ 7
Present Mailing Address a s
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 who.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 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 U5
APPROVAL OF BUILDNG INSPECTOR
See other side for state code
{ CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Construction Debris Disposal Affidavit
(retluired lur all demolition and renovation work)
In accordance \kith the sixth edition of the State Building Code, 780 CNIR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit N is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11. S 150A.
The debris will he transported by:
/ C/ V4
(name of hauler)
'I lit: debris will be disposed ofin
(naine of facility) -
(address A facili(y)
sipatnrc of permit appl
date -- - -..