404 1-2 JEFFERSON AVE - BUILDING INSPECTION GK32 -7 `70o-D
The Commonwealth of Massachusetts
`.? Board of Building Regulations and Standards CITY OF
ya , Massachusetts State Building Code, 780 CMR RECEI IE13. SALEM
INSPECTIONA T RfE"ftS2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only -
BuildingPermitNumber: Date pplied:
Building Official(Print Name) Signature Date
SECTION I:SITE INFORMATION
N 1.1 le � s �e� l 1.2 Assessors Map& Parcel Numbers
/\ I.1 a IIs's this/ n accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rcar Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.],a 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OW ERSHIP'
2, caner of Record �j
Name(Print)
N City,State,ZIP
o.and Street Telephone Email Address
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 Other ❑ Specify:
Brief Description of Proposed Work': _
IN IF VkJ-—r-1 IckL.
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ I. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Costs(Item 6)x multiplier t X
3. Plumbing $ 2. Other Fees: $ /J/}(
4. Mechanical (IIVAC) $ List: jU
5. Mechanical (Fire $
Suppression) Total All Fees: $
'1 Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ ,� V ❑Paid in Full ❑Outstanding Balance Due:
Mal LID q-",) 4 In 1/2 G �
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Nani6'6fCSL,Holdei,AQ1I Ji4elfi
List CSL"type(see below)
No.aand'Strecr:.i P ' Irl"L 111 S Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted I&2 Family Dwelling
City/town,State,ZIP M Mason
ry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(WIC)
HIC Company Name or HIC Registrant Name HIC Registration Number Expiration Date
No.and Street Email address
City/Town,State,ZIP 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...........❑
SECTION 7a: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 authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED 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 0*�ronic 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 not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.ntass.eov/oca Information on the Construction Supervisor License can be found at www.mass.uov/dps
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 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 S�Uz f, >%L-1SS.ACHUSETTS
BU'LOLNG DEP.IRTSE&NT
120 Vfl-kSHLNGTON STZEET, 3°FLOOR
N.
TEL (973) 7 r'5-9595
KIMBERT EY DRISCOL-L F•10C(978) 7.10-934S
NLAYo;2
'I;-toscA3 Sr.PiE.grtg
DIRECTOR OF PUBLIC PROPERTY/HL'(L,OLNG CO-%C HSS[O,NEZ
Construction Debris Disposal
(required for all demolition and renovation work)Yit
In accordance with the sixth edition of the State Building Cada, 730 CD,(R section 1111.5
Debris, and the provisions of 1�(GL e 40, S 54;
Building permit 4is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility 11 1, S I SOA. p p y p
ry as defined by bIGL e
The debris will be transported by:
,y G�6��fSlh�i
(n�mc ut'haulur)
The debris will be disposed of in
(name of tacllity) - -- .
(�ddid"of (lallty)
fISIt:l tife Ut CI'fTllt I, 1
tT If]Ill lllf
f
CITY OF SALEM, MASSACHUSETTS
BUILDING DEPARTMENT
N°I 120 WASHINGTON STREET,Yo FLOOR
TEL. (978) 745-9595
FAx(978) 740-9846
KINIBERLEY DRISCOLL
MAYOR THOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONRAISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASES PRINT:6 Date ^G � 2
Job Location clD S/& t/ /—�� � ✓ U�
Home Owner Address S171-7If
Present Mailing Address _S/1"AZ
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 SIGNATUC��
APPROVAL OF BUILDING INSPECTOR