404 JEFFERSON AVE - BUILDING INSPECTION 1�71
The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
\
? Massachusetts State Building Code, 780 CMR, 7ih edition Building Dept
Building Permit Application To Construct, Repatr, Renovate Or Demolish a �
^^ One- or Tivo-Family Duelling
This Section For Official Use Only
Building Permit umb Date Applied:
Signature: O
Buildin Commissioner/Inspector of Buildings Date
SECTION 1: SITE INFORMATION
I r perty Ad res • 1.2 Assessors Map& Parcel Numbers
� D � �JQ �rS� 1� Ave
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 It) Frontage(ft)
1.5 Building Setbacks III)
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 O Private❑ Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 er of Re o d:Name
(Print) Address for S/ervfi_ e1:
Tel one
SECTION 3: ESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) [3Alteration(s) ❑ Addition ❑
Demolition [3 Accessory Bldg.❑ Numb r of Units_ Other O Specify:
Brief Description of Proposed Work':
5
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ _- ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: S
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire S Total All Fees: $
Su ression
_/ Check No. Check Amount: Cash Amount:
6. Total Project Cost: b J�4O� 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES '
5.1 Licensed Construction Supervisor(CSL)
' License Number Expiration Dale
N,4me of CSL-Helder List CSL Type(see below)
Address RDResi'ledential
Descn Lion
tricted u to 35,000 Cu. Ft.)
Signature nential Roofin CoverinTelephone entialWindow andential Solid Fuel Bumin A liance Installation
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. 152.4 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
fauthorize
NER'S NT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
to act on my behalf,in all matters
ive to work authorized by t is building permit application.
ture of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
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 penalties ofperjury)
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 I I O.R6 and 110.115, 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 S kLEM
PUBLIC PROPERTY
DEPARTMENT
KIMOIFJ"V 0 w.=
MAVM 130 wtivuwnw,STUNT•SMXK MwvAon:sens 01970
To-976.74S-9M*FAx.978-7404M
HOMEOWNER LICENSE EXEMPTION
Pies"Print
Date�
Job Location -O4/
Home Owner Address (14m -
Home Owner Telephone /0/7- ,40—��
Present Mailing Address
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
ar el PUBLIC PROPRERTY
�; ,•� DEPARTMENT
.,
Construction Debris Disposal Affidavit
(required lbr all demolition and renovation work)
In accordance ith the sixth edition of the State Building Code, 780 CNlR section 1 1 L5
Debris, and the provisions of MGL c 40, S 54;
Building Permit tf 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
l 11. S 150A.
The debris will be transported by:
(name of hauler)
I he debris will be disposed of in
(mmne of facility)
l address of facilitvl
1 PVA V�
Signature of pdmnit applii nt
da e