171 MARLBOROUGH RD - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
i,✓1❑ Building Permit Application To Constrict, Repair,Renovate Or Demo[' h a Revised ar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date A lied:
yla
Building Official(Print Name) tgnamre Date
SECTION 1:SITE INFORMATION
1.1 PWs d(I�s„oVk h 1.2 Assessors Map&Parcel Numbers
LIn Is this an accepted street?yes_ no ,(C Map Number Parcel Number
1.3 Zoning Information: - 1.4-Property Dimensions:
Zonmg 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?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP' _
2.1 Ow ert of Record:
Name(Pnnt)-✓/ctA97�(
�// Ctty�$[a[c,ZIP
No.and StreetV Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) _ Alterations) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Rroposed orkz: p C�
i
s
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
1.Building $ ev 1. Building Permit Fee:.$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
[]Total Project Cost.(Item 6)x multiplier x
3.Plumbing - $ 2. Other Fees: $
4.Mechanical (ITVAC) $ List:_
G 6
5. Mechanical (Fire ..,
Su ression) Total All Fees:$
6.Total Project Cost: $ ,?J 1.h1 Check No. Check Amount: Cash Amount:
11 Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
Name of CSL Holder
License Number Expimbcm Date
List CSL Type(see below)
No,and Street Type •- Description
U Unrestricted Buildin s u to l5 nn 1 cu,ft.
Crty/Town,State,ZIP R Restricted 1&2 Family Dwelling
M Mmu
RC Roofn Coverin
WS Window and Sidin
SF Solid Fuel Bursting Appliances
I Insulation
Tel hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
i
HIC Company Name or HIC Re HIC Registration N strap[Name g umber Expiration Date
No.and Street
Email address
Cr /Town,State,ZIP Tel hone
r' 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 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
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 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 1 is application is a and accurate to the best of my knowledge and understanding.
P ' [ wner's or Autho gent's Name(Electronic Signature) Date
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 not have access to the arbitration
program or guaranty fund under M.G.L.a 142A.Other important information on the HIC Program can be found at
www.mass.aov/oca Information on the Construction Supervisor License can be found at MnW mass gov/dos
2. When substantial work is p] ned,provide the information below:
Total floor area(sq.ft.) (y (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 s stem
y Nu
mber of decks/porches /
Type of cooling system
Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
CITY OF &U E,NI, 2N'LXSS.ACHUSETTS
BuILDLNG DEPARTMENT
130 WASHNGTON STREET,3tO FLOOR
` T F-L. (978) 745-9595
KIJ(BERLEY DRISCOLL FAX(978) 740-9846
MAYOR T HO&IAS ST.Pmm
DIRECTOR OF PUBLIC PROPERTY/BUILDITNG COMMSSIONER
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 150A.
y
The debris will be transported by:
e,
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit applicant
slate
dcbrisatrduc
CITY OF S.U-ENf
PUBLIC PROPERTY
DEPARTMENT
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HOMEOWNER LICENSB EXE.Mnj0V
Flew hint
Date �,6-
Job Location
Home Owmr Addm@s /7/ / o/ci' o
Home Owner Telephone c
Present Mailing Address _az--r c/ _ 1,9 77
The current exemption of"Homeowners"was extended to include owner-0ecupied
dwellings of two Units or teas and to allow such homeowners to engage an individual for
hire who does not pouees a ticensq provided that the owner acts as supeavisar.
DEFINMON OF HOMEOWNER
Persons) who owns a parcel of land on which hdsM resides or Intends to resider on
which there is, or is intended to bob a one or two family dwelling attached of detached
struotttres accessory to.such use and/or farm structures. A person who construct@ more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Ofllcial,on a form w"Ttabis to the Building
Official, that hdshe be responsible for all such work performed under the Building
Permit
The undersigned "horneownea'uaumes responsibility for compliance with the State
Building Code and other applicable by-laws and retuladons.
The undersigned "homeowner"centill s that hdihe understands the City of Salem
Building Department minimum inspection procedures and requirements and that hdshe
Nill comply with said procedures and requirements.
HOMEOWNERS SIGNATL•RE / �y
APPROVAL Of BUILDING GYSPECTOR �
See other side far state code