7 MAPLE AVE - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
v. FOR i
Board of Building Regulations and Standards MUNICIPAIXI Y
•,i� Massachusetts State Building Code, 780 CMR, 71h edition (ISE
W Building Permit Application To Construct, Repair. Renovate Or Demolish a Rcioed Jmu,w,
One- or Tiro-Funnily Duelling 1, 'ix)g
This Section For tct 1 se Only
� Building Permit Nu /r�: to A lied:
Signature: r" '" /
Building Commission Inspector of Butt
n s Dute
SECTION 1: SITE INFORMATION
y1�Pro r % d es�j J� 1.2 Assessors Map & Parcel Numbers
Ma Number Parcel NunihLr
I.la Is this an accepted street'?yes no P
1.3 Zoning Information: L4rrtY,Dimensions:
G
Zoning District Proposed Use
Lot Area(sq n) Frontage(ft)
1.5 Building Setbacks(h)
Side Yards - Rear Yard
Front Yard
Required Provided Required Provided Required Pn>viJld
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 IO(On site disposal system ❑
Public Private❑ Check if XesO
SECTION 2: PROPERTY OWNERSHIP'
Z1g rtolRec d:Lr/ L€ IYJ
i/ FC r
ddre�s+sfor Service/S�a=—FeF—
STelephone
ECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
P P 40 Addition ❑
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repair Alteration(s)
Demolition ❑ I Accessory Bldg. ❑ 1 Number of Units_ I Other ❑ Specify:
f p�crip[ion of roposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials)
1. Building $ /d �� 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: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ vu Total All Fees: $
Suppression)
' Check No. Check Amount•. Cash Amount.
6. Total Project Cost: $ Z ° ❑ Paid in Full ❑ Outstanding Balance Due:
ReS,'R"Qn L
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 1
License Number Expiration Date
Name ul CSL- Huller
List CSL Type(see below)
Address Type I Description
U I Unrestricted(up to 35.000 Cu. Ft.t
ItRestricted 1&2 FamilyDwelfin
Signature M Masonry Only
RC Residential RoofingCovering
Telephone - \VS Res:a, ial Window and Sidra
SF I Residential Solid Fuel Burnm A )hank histallation
D I Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Nunber ,��Ste.
Address
Expiration Date
Signature sTelephone .
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.9 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure at provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... O No ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
i. as Owner of the subject property hereby
authorize` s to act on my behalf, in all matters
relative to'work'authorized by tF s building permit_application. A A\
v
Signature of Owner - Date
SECTION 7/ I
b: OWNERt OR AUTHORIZED AGENT DECLARATION
a, i`�. / r � ,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
be If.rin
�
Signature bCQvmeror 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 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 110.116 and 110.R5. respectively.
2. When substantial work is p/lanned, provide the information below:
Total floors area(Sq. Ft.) f X �� (including garage, finished basemenbattics.decks or porch)
Gross living area(Sq. Ff.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halt/baths
Type of heating system Number ot'decksl porches f
Type of cooling system Enclosed 0 `t' X Open
3. "Total Project Square Footage" may be substituted for Total Project Cost"
CITY OF SALEM
iF PUBLIC PROPRERTY
1011-
DEPARTMENT
120WAS1 HNG!ONSCRLET 0 $A I INt, It ti[%I I SO19/_
I FI,: 978-7439;95 4 17AX:9/18 743-9846
Construction Debris Disposal Affidavit
(re(lt.lited 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 c 40, S 54;
Building Permit ft I-__ is issued with the condition that the debt-is resulting front
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 b
z LAI/1-s7-4-(ranic of hauler)
I'lle debris will be disposed of in
A4 0-2- L-,/ 7<_ Ai-j)"o vq-(_
/3
(11aineoffacilit
Coe �y
L0 44 C
(address of facility)
signature of permit applicant
o
(late
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KIl01�!�v n�w•v
.MAW* 130 WA94NCMN STU=•SAA EM A%MACHLSEM 01970
lli 978-74S-9S9S * FAx 973-740.964
HOMEOWNER LICENSE EXEIMMON
Please Print
�
Date � 4 `
Job Location 2 �L7 -w C f- i1 d
Home Owner Address, M/�/'L C
Home Owner Telephone 6 7
Present Mailing Address P� -
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 dwellin& 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 fort 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 procedure—saiLad requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTORS/�'u//'� cam, i
See other side for state code