401 JEFFERSON AVE - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standardsj
Town of
Massachusetts State Building Code, 780 CMR, 7'"edition
Building Dept
d Building Permit Application To Construct, Repair, Renovate Or DeOne- or Two-Family gThis Secti or Official Use Only
Building Permit Number: Date ppl'ed-
Signature: i r1!1,
Building Commissioner/In ector of Built s ate
SECTION 1: SITE INFORMATION
I.1 Property Address: //����-- 1.2 Assessor Map& Parcel Numbers
fC O 1 J �f r Prho� A—c9 r� , )' /
I.1a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: !A Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(II)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required ovided Required rovided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private O Zone: _ Outside Flood Zone?Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner[ Kec r
Name(Print) ' Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition y Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
--��� 'QED ••S ''nS � •"L4 o+n/>
Sl JC Alan^ 0 00 La
I
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Offlcial Use Only
Labor and Materials
I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ ❑ Paid in Full ❑Outstanding Balance Due:
4 Ll
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 9 T O q
1
••- License Number Expiration Date
N.qme of CSL- Helder List CSL Type(see below)
- T -Description
U Unrestricted(up to 35,000 Cu. Ft.)
R Restricted I&2 Family Dwelling
Sig at r �,,, M Mason Only
'�'�C/ RC Residential Roofin Covering
Telephone WS Residential Window and Sidin
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.§ 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...........
13
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
L'/.f/jT/;'as Owner of the subject property hereby
authorize tom— 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 2enaltics of du
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. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 I0.116 and 110.R5, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basemenUattics,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 be substituted for"Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
3r, f - <
DEPART'.vIENT
III Y'8 '4 1'\V 778..'4},54�
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance �%ith the sixth edition orthe State Building Code, 780 CNiR section 1 1 1.5
Debris, and the provisions of'v1GL c 40, S 54;
Building Permit It is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I 11. S 150A.
The debris
//will be transported by:
(name of hauler)
I he debris will be disposed
/of inJ:
l9l'�S��GY-� (6irT�tr
(mm�r ul facility)
(address u(laeility)
signamrc of prnnit applicant
,late