162 MARLBOROUGH RD - BUILDING INSPECTION (2) •_
11 a the Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
f{ ! Massachusetts State Building Code, 730 C'MR, 71h edition OF SALEM
U �' •i Revised J<inuun•
Building Permit Application To Construct, Repair,Renovate Or Demolish a 1. 111118
One-or Two-Funnily Di e
This Section Fo Bicial UA y
Building Permit Numb Date Appr
Signature:
Building Commissioner/Inspector of Bui di Date
SECTION 1:SITE INFORMATION
I."r Le ZQJ7r�J 9,u, ) 1.2 Assessors Map& Parcel Numbers
I.I a Is this an accepted street'?yes 1/ no Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sit 11) Frontage(n)
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? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2 1 Owner'of Record:
prtr.o f� L4an1l� 1�,
CC2j�Ll I&R A.-IC'riiho r cugk) 96
N a(Print) Address for Service:
•
S ignatur Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building O Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work'-:
d/I .ernca^Ila C
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Offlclal Use Only
(Labor and Materials
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
}. Plumbing S 2. Other Fees: S
4. Mechanical (fIVAC) S List: '7 )
5. Mechanical (Fire S
Total All Fees: S
Suppression)
Check No. Check Amount: Cash Amount:
6. Total Project Cost: .S •SOCD,OD 13 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number1piratiun Date
Name of CSI.• I[older
List C'SL Type(see below)
F Description
Address I I lnrestricted tip to 35.000 Cu.Ft.)
12 Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC Residential Routing C'u%erin
Tclephone 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 IIIC 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 7n: 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.
Signature of Owner Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
ea gn< )�) • 6�-JeddO ,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.
L-Ga-n n.e- � - C Fa Ada
Signature tf Owner or Authorized Agent Date
(Signed under the pains and penalties 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(IIIQ Program),will not 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 730 CMR Regulations I IO.R6 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.) I)abitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halfibaths
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"
k ..
CITY OF S.0 E..Nf, NL-1SS.ACHUSETTS
• Bl;MDIING DEPARTNIENT
130 WASHLYGTON STREET, 3iD FLOOR
T m (978) 745-959S
FAX(978) 7449846
Ki\®FjU-EY DRISCOLL
MAYORT1touAs ST.PtERRs
DIRECTOR OF PUBLIC PROPERTY/BCILDLNG CONLMISSIONER
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 1 l 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit Al 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
l 11, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
P JDYE 510tt
C,
(name of facility)
Swaj-) P--�cotf- RoL- CSaLcr-t rtA.
(address of facility)
signature of permit applicant
elate
dabnatf d•�:
CITY OF S. yLVI
PUBLIC PROPERTY
DEPARTMENT
1301FAYYIA. OM h1tR.SAI am V zLh0&*SVTSo19'e
r9L 9-5.7 -9s"*FAX 978-74e•9"
HOMEOWNER LICENSE EXEMPTION
Plea""I
D. ul'th 1
Job Location IIDa W4rl P-ek 00-Le,rz1-, rL-P- _
Home Owner Address S
Home Owner Telephone R'78'- r V-L4 - q1 1
Pressor Mailing Address Sam-0—
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
him who.does not possess a license provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s) wbo owns a parcel of land on which he/she resides or intends to resider on
which there is.or is intended to be.a one or two family dwwellLug, 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
Otllcial, 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 requirements.
HOMEOWNERS SIGNATURE X,
APPROVAL OF BUILDING INSPECTOR 2 `'
See other side for state code