171 MARLBOROUGH RD - BUILDING INSPECTION (4) 'File Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR SALEbI
Revised.Nnr 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Divelfing
This Section For Official Use Only .
Building Permit Number: D e pplied.:
Building OtTicial(Print N: e). ignat ate
SECTION G SITE INFOIMATION
LI Property Address: 1.2 Assessors Map& Parcel Numbers
% 7 / iN �f2t bur;L d A
I.Ia Is this an accepted street?yes s/ 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(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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
.. to r. 4 e r S u'� �L h C�. SLv 1 P Yh T^"\ As
S
N ine(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) -Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work: �i ems_ l= r-. «--
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building S I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S r' `Z _ ❑Total Project Cost'(Item 6)x multiplier s
J. Plunibing S j 5 0 ( 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S
Suppression) 'Fond:\II Fees:S
Check No._Check Amount: Cash Amount
6. 'rotal Project Cost S '?1 ` ` ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL'rype(see below)
No. and StreetType Description
U Unrestricted(Buildings up to 35,000 cu. It.)
R Restricted 1&2 Family Dwelling
Cityfrown,State,ZIP NI Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
I IIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town, State,ZIP 'rele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.151§ 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'
I,as Owner of the subject property,hereby authorize
t9 act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Nane(Electronic Signature) Date
SECTION 7b:OWNEW 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 this application is true and accurate to the best of my knowledge and understanding.
Print Owner'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 NLG.L.c. 142A.Other important information on the HIC Program can be found at
w ww.mass."ov"oea Information on the Construction Supervisor License can be found at www.mass.sov!d tM
2. When substantial work is planned,provide the information below:
'total floor area(sq. ft.) (including garage, finished basementlattics,decks or porch)
Gross living area(sq. R.) 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"
CITY OF SALEM, tiLuSACHLSETTS
BL'IMLNG DEPAR11t&NT
N 120 WASHLNG-rON STREET, P F2.00R
TEL (978) 745-9595
FA.K(978) 740-9846
KI- f Y DItISCOLL
Rs
,1$,1YO R THomjui ST.PtER
DIRECTOR OF PUBLIC PROPERTY/BUILCING CONI]MISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S i50A.
The debris will be transported by:
Zn� c S
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility) -
signature of permit applicant
0C_4— /1 2 0 13.
date
Iobrl.m LJ.x
CITY OF SM EM
PUBLIC PROPERTY
DEPARTMENT
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HOLMEOWNER LICLNSS E.Xj.Wnj0,V
Pleas# prize
Data
job Loesd" 1 7 1 Y*.v) \ rn- C_ {2
Home Owner Addrw 1 -1 � vv,c,.- 1 b a r
Home Owosr Telephoae Y 7 �- c% 2 ICI G
Present M&Ubg Addrea 1 -7 1 na o rt l b ,.( ✓� t S P
Tie current exemption of"Homeowner"wee extended to include ownar accapied
dweUinga of two Unite or feet red to allow Ruch homeowner to angsge as individual for
hire wbo,doe not posse=a Utms%provided that the owner acts as mparvisor.
DEFINMON OF HOMEOWNER
Pawn($) who owns a parcel of lead on which hdA@ rexidea or Intends to raider oa
which them is, or is intended to ben a one.or two &milt'dwelling, attached or detached
Rtnxftwm accessory to such use and/or r3rm Rgvcturea A penoa who constructs more
thm one home in a two year period 1W not be considered a homeowner. Such
"homeowner"Rhall Rubmit to the Building Om7ci4 on a form acceptable to the Building
Official, that hdah@ be reaponsible for all Ruch worhperformed under the Building
Permit
The undenipfed "homeowner'&Morel rea nsibility rot compliant@ with the Stu#
Building Code and other ipplicable*14wf and reguladon&
IN undeniypnat "homeowner"certiRa that hdfhe undentands the City of Sslem
aWldinl Dryatment minimum inspection procedures and requirements and that hdahe
-viIf comply with laid pmeaiures and requirements,
HOMEOWNERS SIGMA M'M
�PPRDV,1 L OF BUILDlVG rr'SPECTDR
See other fide for site code