9 LARCH AVE - BUILDING INSPECTION (5) 4
/ The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
FJ / Massachusetts State Building Code, 780 CMR, 71h edition OF SALEM
y Revised January
Building Permit Application To Construct,Repair, Renovate Or Demolish a 1. 2008
One-or Tivo-Family Dwelling
This Section For Official Use Only
Building Permit Numb r: Dale Applied:
Signature: &Ag ,
Building Cummissione nspector of Buil ngr ate
SECTION Y:SJVE 1 RMATIO
1.1 Property Ad�es�s: '/ 2 As ssors Map& Parcel Numbers
Y �a't.H �/ d/l�
I.l a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zuning District Proposed Use Lot Area(sq 11) Frontage(11)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownert of Record:
Swr/, Gh C4. rr� 9 /a /-e4 awe Sa/e.a.
Name(Print) Address for Service:
Signature Telephone
SECTION 3:D SCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) X I Alteration(s) ❑ Addition Cl
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work'-:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (BVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
Check No. Check Amount: Cash Amount:_
6.Total Project Cast: S (�� 0- 13 Paid in Full ❑Outstanding Balance Due:
r
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Dale
Name of CSL I lolder List CSL Type(see below)
rype Description
.Address U Unn"arictcE
u to 35,000 Cu.Ft.
R Restricted 1&2 Famil Dwelling
Signature M Masonry Only
RC Residential Roofing Covering
relephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
tIIC Company Name or HIC Registrant Name Registration Number
Address Expiration Dale
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
, 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.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the Rements and information on th regoing application are true and accurate,to the best of my knowledge and
behalf. r
Print Nam
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury)
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 no.1 have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and I IO.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'
's CITY OF SALEM
PUBLIC PROPRERTY
' DEPARTMENT
I .1"x I'0A*.%'IIIM...@4Sr Ott r •S.utM. %f.%,4 Iu 1 •:1't'.
l'rl:v:t•:t!'�;'9 F.VC:s�s•7+S Is+�
Construction Debris Disposal Allidavit
(required tur all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40,S 54;
Building Permit p 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)
1'Ite debris will be disposed of in :
(nume of aei ny .
(addrinx of I;tcility)
V .lipnalwe of IxrmU ipphcant
date
I\I'.1•dl 2ti
CITY OF S.XLE.N1
PUBLIC PROPERTY
DEPARTMENT
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HOMEOWNER LICENSE EXEMPTION
Please Prtrat
-
Job Location
Horne Owner Address
Horne Owner Telephone
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 whor does not possess a license,provided that the owner acts as supervisor.
DE INMON OF HOMEOWNER
Peson(s)who oats 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 r. eme .
HOMEOWNERS SIGNATURE pnts
P
APPROVAL OF BUILDING INSPECTOR
See other side for state code