13 MAPLE AVE - BUILDING INSPECTION Z, The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7m OF SALEM edition Revised Junrnrry
Building Permit Application To Construct, Repair, Renovate Or Demolish a /. ;408
\� One-or Two-Family Dwelling
j 1 This Section For Official Use Only
Building Permit Number: Date Applied: Zt 02C)' 2Z ZO/d
` Signature: 7(r)
dt-\ Building Commissioner/Inspector "Bilildings Date
SECTION I:SITE INFORMATION
.1 PropertyAddreli: I� 1.2 Assessors Map& Parcel Numbers
I.la 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(11)
1.5 Building Setbacks(R)
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?
Pu is❑ Private❑ Check if es❑ Municipal❑ On site disposal system O
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownert of Record:
Pefe� Four
ame(Print) Ad for Service:
Signal - Telephone
SECTION 3: DESCRIPTION OF PROPOSE WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑
Demolition Accessory Bldg.❑ mbar of Units_ Other ❑ Specify:
Brief Description of Pro reed Work': o CY /t t'x i Ji
r�
Yv C U t
SECTION 4: ESTIMATED CONSTROCTIO14 COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S S'CI d O I. Building Permit Fee:S Indicate how fee is determined:
❑Standard Cityrrown Application Fee
2. Electrical S 00 ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S T-0 0 List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No. Check molt: Cash Amount:
6. Total Project Cost: S /b^ 0 0 t) ❑Paid in Full 13 Outstanding Balance Due:
r ,
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expimrion Date
Name of CSL- I lolder List CSL Type(see below)
flRC
Description
Address Iinrestrictcd u to 35.000 Cu.Ft.
Restricted 182 FamilyDwelling
Signature Maso Only
Residential Rocfin Coverinrelcphone Residential Window and SidinResidential Solid Fuel Bumin A liance Instal lalion
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. 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 79: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.
Si at re of Owner Date
SECTION 71b:OWNER'OR AUTHORIZED AGENT DECLARATION
1 ' ' f ,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
e� Fa ss
mtN a ZL ZdJO -
ature of-Owner or Authorized Agent 'Date
(Signed under the pains and penalties of du
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 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 I I0.R5, 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 beating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
l
CITY OF SALE.NI
PUBLIC PROPERTY
DEPARTMENT
u.o�aur os�•�
wroe 130Wmw.c.� 3MM•s,u r,K MnanoRsans 019-0
TIM 973.715-9s" • FAX 976-746964e
HOMEOWNER LICENSE EXEMPTION
Please Print
Date v
Job Location
Home Owner Address
Home 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 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 struettures. 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 r -fined responsibility for 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 requirempents. /
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SALEM
i PUBLIC PROPRERTY
DEPARTMENT
I'.1:: MI,1 ''Illy''•11
I SC\t•.\V IL\b.•�H 1 rM kl'i �)•\I I fl, \L\�i\/ I II V I,•.1'r•.
I'rt:v:t.T�S•t}'�S s f\!c:v7f•NS•ra
Construction Debris Disposal Affidavit
(retluired Iur all demolition lull renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section I 1 1-5
Debris, and the provisions of MGL c 40. S 54;
Building Permit p is issued with the condition that the debris resulting from
in r properly licensed waste disposal racility as defined by MGL c
this work shall be disposed or
111. S 150A.
The debris will be transported by:
/•� ram!r�. •�%.
I lama of hauler)
The debris will be disposed of in :
(macro- facility)
plddrc.II u) txJuy/ 79 HL
.I azure off Iwrmit�pplicaM
y/ Z2/ 2d � a
(late
L In I•.11 .�