7 MANSELL PKWY - BUILDING INSPECTION S
hThe Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
y G OF SALEM
Massachusetts State Building Code, 780 CMR, 7"' edition
Revised Jartoary
Building Permit Application To Construct, Repair, Renovate Or Demolish a i. =008
ne-or Two-Fare y Divelling
This Sectio or Official Use Only
Building Permit Number: Date Applied: '2' 'U
Signature: ��2'I r 'Olt
Building Commissioner/1 t uildings Date
S TION I: SITE INFORMATION
1.1 Pro erty Address: 1.2 Assessors Map&Parcel Numbers
E LL, P Kw -
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 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Pruv ided 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? Municipal❑ On site disposal system ❑
Check ifyesO
SECTION 2: PROPERTY WNERSHIP'
2.1 Wer'of RecorEC' id,A "7 5,;� PKW Y
Na r' t) �tAdd ss t Service:tDj S �� It
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction ❑ Existing Building jO Owner-Occupied tf Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. Ni er of Units Other Specify:
Brief Description of Proposed Work' 2..
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
I. 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 S 2. Other Fees: S
4. Mechanical (FIVAC) S List:
5. Mechanical (Fire S
Su ression Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S ❑ Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL- Iloider list CSL Type(see below)
Fy ne Description
Address U Unrestricted(Lip to 35,000 Cu.Ft.)
It Restricted 1&2 Famil Dwelling
Signature M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I-IIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature 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.
Sianature of Owner Date
SECTION 7b':'OW�NE LRt 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. IG,Wt�& ` u
Print Name
ignature of Owner or Authorized Ag t Date
Signed under the pains andpenalties 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 IO.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"
1 _ _
CITY OF S.ULS.NI
PUBLIC PROPERTY
DEPARTMENT
w,aursv o�suaL
Vwroa 130 WAf MIGU M JMMW.SW14 VANAO&SIF111 at.'0
t1n.Y'L7s-9s11.v.ub f7L1�69w
HOMEOWNER LICENSE EXEMPTION
Please Mat
Dan 2 2 vi I
job Location IUAN(ELL, Nomy
Home ownat Addrw
HomsOwnsr?elephons 117IK SAXV ►S("
Present Mailing Address
The current exemption of"Homeowners"was extended to include ownar-occupied
dwellings of me Units or less and to allow such homeowners to engage an individual for
him who.does not poaen a Heenan provided that the owner acts as supervisor.
OM71NIITON Of HOMEOWNU
Person(a)who owes a parcel of land on which ha/she resider or iatands to raider on
which there iq or is intended to bsr a one or two fluidly dwelling,attached or detached
sauctura accessory to such use and/or firm 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 Officiak on a form ueeptable to the Building
Official, that he/she be responsible for ad such work performed under the Building
Permit.
The undersigned"homeowner"assumes responsibility for compliance with the Stab
Building Code and other applicable bylaws 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 uirements.
HOJ4EOWNERS SIGNATURE
APPROVAL OF BUILDING NSPECTOR
See other side for state code
A
:r
CITY OF SM EM. xSSACHUSETI'S
• BUILDIING DEPARTMENT
' 120 WASHLNGTON STREfiT.3i0 FLOOR
T EL (978)745-959S
FAX(978) 740.9846
KIJiBHRL EY DRISCOLL
T
MAYOR ftoausST.PtPotR
DIRECTOR OF PUBLIC PROPERTY/BCIIDNG COMMISSIONER
Construction Debris Disposal Affidavit
(required for 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 a 40, S 54;
Building Permit a# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by: /
tS MTV
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit pplicanP
date
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