1 LEVAL RD - BUILDING INSPECTION (3) $2-LS, GSH ez:G-r `I 37 W3'�
st The Commonwealth of Massachusetts c
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR Sd15✓
Revised 1�201 --
Building Permit Application To Construct, Repair,Renovate Or Demolish a 1 n
One-or Two-Family Dwelling a�*t
This Section For Offici Use Only
m
Building Permit Number. Date pplied:
UJ �
Bwlding Official(Print Name) Signature _ Dated.. •r'
— SECTION 1:SI , INFORMATION
( a .{ ,, 1 /� 1.2 lessors Ma &Parcel Numbers
1.1 Property rty Address: .4 L�VIeLI „� P
l 1.1a Is this an accepted street?yes_ no Map Numbe . Parcel Number
111 1.3 ing Information: 1.4 roperty Dimensions:
Zoning DistrieN, Proposed Use Lot Area(sq Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Require Provided Aequved Provided uued Provided
1.6 Water Supply:(M:G.L c.40,§54) 1.7 Flood Zone-Information: '1.8 Sewage Disposal System:
Public 11 Private 11 Zone: _ Outside Flood Zone?Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 err of Record: i } t!� .\/ T 0-I-(_6 n �t 4 , d A D ' '76
Name(Print) d City,State,ZIP I'V 1
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑TExisting Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Wo
pQr>;tct1 Rg.moya o x Iy1141N0c1 M01
v of
SECTION 4:ESTIMATED CONSTRUCTION COSTS l
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ O 0D 1. Building Permit Fee:$ Indicate how fee is determined;
2.Electrical $ ❑Standard City/Town Application Fee
C3Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:.
5.Mechanical (Fire $ Total All Fees:$
ression
Check No: Check Amount: Cash Amount:
6.T tal Project Cost: $ 3, 15 D C) ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date 5
Name of CSL Holder `
List CSL Type(see below)
_ No.and Street
,Type " Description ,
U I Unrestricted(Buildings up to 35,000 cu.ft.
` fr R I Restricted 1&2 Family Dwelling
City/rowa,State,ZIP M I Masonry
RC I Roofing Covering
WS I Window and Siding
" SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(RIC)
BIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
Ci /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 APPLIE$FOR BUILDING PERMIT`.
I,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.
20A0-1d S. IJd-/ ion syIg ��6
Print Owner's Name(Electro "c Signature) Date
SE ION 7b:OWNER' 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.
P " t Mor Authorized Agent's Name(Electronic Signature) Date
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 can be found at
w�anv.mass.gov(oca Information on the Construction Supervisor License can be found at www.mass.eov/dns
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"
1
QTY OF SALEM, MASSACHUSETTS
BUILDING DEPARTwNr
120 WASHINGTON STREET,3RD FLOOR
TEL. (978) 745-9595
KIMBERLEYDRISCOLL FAX(978)740-9846
MAYOR TYfOMAS STTIERRE
DIRECTOR OF PUBLIC PROPE RTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date
Job Location `� C CLr,,I k4l./ Sa 14rn, o 117 b
Home Owner Address SQ rn
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 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 SIGNATURE � O. &J,1�a„zJ `' `S' " a l7�o�J✓
APPROVAL OF BUILDING INSPECTOR