402 JEFFERSON AVE - BUILDING INSPECTION The Commonwealth of Massachusetts
�\ W11,
Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 71h edition
Building Dept
Building Permit Application To Co ct, Rep , Renovate Or Demolish a
One-or T o-Family Dive! ig
Th' Section For Official se Only
Building Permit Num er: a Ap ied:
Signature: "q
Building Commissioner/Inspector of Idin s Date
SECTION 1. SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
40 a 3 a F iF QP .A t3 1°v J�
1.1 a Is this an accepted street?yes_ no_ Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq III) Frontage(ft)
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,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
{aA-r.tw'Q.o '(` �
Name(Print) Address for Service:
Amy '
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work': --S •�t al a r� /�fiSY �.aao��-� �C'�c
_ (2,c�%c e. WALL —"tcl S-0-04>„�oh��
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building Permit Fee: $ Indicate how fee is determined:
1. Building $
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ Total All Fees: $
Su ression
Check No. Check Amount: Cash Amount:
6. Total Project Cost: 1
0 , 13 paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
,..
' License Number Expiration Date
Name of CSL- Helder List CSL Type(see below)
Address - T D
escription
U Unrestri000 Cu. Ft.)
Signature R Res reFamily Dwelling
M ason
R Residentiverin
Tcle ne S Residentid Sidin
SF Residentiumin Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
—Ea iration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT 52.§ 25C(6))
Workers Compensation Insurance affid itue completed and submitted with this application. Failure to provide
this affidavit will result in tal of the Issuance of the building permit.
Signed Affi t Attached? Yes .......... ❑ No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I• as Owner of the ro subject 3 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: OWNER' OR AUTHORIZED AGENT DECLARATION
_3---x ,as Owner or Authorized Agent hereby declare
that the statements and informationb�the foregoing application are true and accurate,to the best of my knowledge and
behalf. ^
Print N
VOL 6- 00
Signature of Owner or Authorized A nt Date
(Signed under the pains and penalties 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 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 I I O.R6 and I I O.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"may be substituted for"Total Project Cost"
CITY OF $.ULEM
PUBLIC PROPERTY
DEPARTMENT
IV�0��QV N14YY 1
MAVO• 130WASUPICTM STREET 9su®awsA0ft=Mm970
Tm.97L743-95"•F.zc 975-740.9646
HOMEOWNER LICENSE EXEMPTION
Please Print
Date :�- :?(.- pot
Job Location y a-FF o is a a POLL L S H Z a.,. ntiw o 112j
Home Owner Address
Home Owner Telephone 912 -a7.9e—9 91 `f
Present Mailing Address s 4)- +..dl.-
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
APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SALEM
4
PUBLIC PROPRERTY
DEPART'/TENT
Construction Debris Disposal Affidavit
(required lbr all demolition and renovation work)
In accordance ith the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of:ti1GL c 40, S 54;
Building Permit ft is issued with the condition that the debris resulting from
this work shall he disposed of in a pruperly licensed waste disposal facility as defined by MGL c
I 11. S 150A.
The debt-is will be transported by:
(name of hauler) 10-11
I he debris will be disposed of in
(name of facility)
(address of facility)
signatu,n of permit appl mrt
.:) - A6- a
date