167 MARLBOROUGH RD - BUILDING INSPECTION 12t�7o<r 4-Z:l I
The Commonwealth of Massachusetts
' OF
Board of Building Regulations and Standar ECEIVED CITY M
Massachusetts State Building Code,(7j�t1ONAL $ERVIC S SALE
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling _b P 3' 2 1
p This Section For Official Usg Only
Building Permit Number: Date Applied:
Building Official(Print Name) -Signature Dat
SECTION 1:SITE INFORMATION
1.1 Pro erty Address: 4 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 ft) Frontage(ft)
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'
y Owners o ecord:
tSit n o h M p1 J byl
Nam riot) City,State,ZIP
MAr(,Li�^i aLI j,4 L1A>710.GJ�
No.and Street Telephone Emai] ddress
SECTION 3:DESCRIPTION OF PROPOSED WOR10(check ali that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work2:
„ter rJ I�y;—set � Mcw d7[k� i JI.ir7nw t.J(boc' KC>U!1
1
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.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 $ 2. Other Fees: $ --(-N
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
�( Suppression) Total All Fees.$
` d 1) Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 1 D
�i ❑Paid in Full ❑Outstanding Balance Due:
MlattAE�U -l �lo
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insation
Telephone Email address D Demulolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/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 Tat OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES 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.
Print Owner's Name(Electronic Signature) Date
SECTION 76: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 is pplication is true and accurate to the best of my knowledge and understanding.
Print er's or 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
wnvw.mass.eov'oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
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"
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QTY OF SALEM, mmsAaim m
I B=jNG DEPARTMENT
120 WAsmNGToN STREET,31mFLOOR
I L.(978)745-9595
FAX(978)740-9846
KIlv18ERLEYDRIS�LL
MAYOR THCMAS ST.PIERRE
DIRECTOR OF PUBLiCPROPERTY/BUIIDING COMaUSSIOMR
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 c40, S 54; Building Permit if is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
Ndr7� s)q'
(name of facility)
12'In !=aireb AP/(
(address of facility)
ignature of applicant
Date
QT'Y OF SALEM, MASSACHUSE TTS
BUILDING DEPARTMENT`
120WASHINGTONSTREET,3RD FLOOR
TEL. (978) 745-9595
FAX(978)740-9846
KINMERLEY DRISCOLL
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPE RTY/BUILDING COD&USSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date
lQ l r
Job Location "ArLA&1_0Y3kl Rd S e_A, A419 6l ?7 U
Home Owner Address SAM 2
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. Q
HOMEOWNER'S SIGNATUREa x �"`" � A
APPROVAL OF BUILDING INSPECTOR /