11 MASON STREET - BPA-12-393 The C-onunonwe:dth of M:ssacitusatts
y;. ',� Board of Building Regulations and Standards CITY OF
11 ')• ; Massachusetts State Building Code, 780 C'MR SALEM
y •' RrriscJ.lGu•_'llll
Building Perinit Application To Construct. Repair. Renovate Or Den)olish a
(Err- or Two-Familr Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
fCLL�K, Lam-curt,,.& --
Building Official(Print Name) Signature )utc
SECTION I:SITE INFORNIATIO
1.1 Property Address: S�e2 f 1.1 Assessors Nlap& Parcel Numbers
II ►�-10.Stm
I.la Is this an accepted street?yes ✓ no Nlap Nmnbcr Parcel Numher
1.3 Zoning Information: 1.4 Property Dimenslons:
Zoning District Proposed Use Lot Area(sq 11) 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.1.c.40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposals)Check if 'es❑ P posal s stem ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownert of Record:
1^u t t . dos e- r-o Sec l o,ti, o I a'1 ip
N;una(Print) City,State.ZIP f
11 gQSn n Sfrer f rLgq z) 7
Nu.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) O Addition O
Denwlition ❑ Accessory Bldg. ❑ Numberof nits_ Other ❑ Spccify:
Brief Description of Proposed Work': I
S
SECTION 1: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and \laterials) Official Use Only
1. Building S 1. Building Permit Fee: E Indicate how fee is determined:
_. Electrical S ❑Standard City/Town Application Fee
i ❑Total Project Cost(Item 6)x multiplier — x _
. Plumbing S ]. Other Fees: S
4. .Mcdsmical Ill\ \C) S List:- -- __ --
15. .\fcchanical (Fire ((�
Su,iressionI S Tut:iAllFees: S
o. Total Project Cost: S V ou ('hcck No, ___('heck :\mount: --- C a, h .\mount: -
❑Paid in Full 0 Outstanding Balance Due
SECTION 5: C INS"I'RUCTION SERVICES
5.1 ('onstruction Supervisor License(C'SL)
License Numher"--- --' IRpir tkm Date
N;unc ol'CSI. I hddcr - -_"-"—
List CSI.1)pc(.cc below)
pe Description
No. and Street --------------- "--------- 'I)
it l4trestriilcd IBuilJings ti In}5,0I)0 cu. It.)
#D1
Rstricted 1&?Tamil Dwelho
Citei faw n,.State.LlP sonwlitndow:tad Sidinid Fuel Burning Appliances
ulation
I cic hone 1!mail address molition5.2 Registered Home Improvement Contractor(HIC)
gistr;uiun Numixr Fspirnion Date
I IIC Compan) Name or IIIC Registrant Name
No. and Street Email address
City/Town. State,ZIP rmo hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.11 c. 152.4 15C(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.......•...13
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 ehalf,in all matters relative to work authorized by this building permit application.
,L 10120111
' nt Owner's Nmne(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 Authurired.\gents Nance(Ftcctrunic Signature) D01e
NOTES:
\n Owner svho obtains a building permit to do his her own work,or in owner who hires an unregistered contractor
(not registered in the Hume Improvement Contractor(HIC) Program),will nu have access to the arbitration
program or guaranty fund under I.G.L.c. 1 4'_A.Other important information on the HIC Program can be liwnd at
���„t n�.n. .•. � i Information on the Construction Supervisor License can be found at �Io\ Illh.
2. \\'hen substantial Iwrk is planned,provide the information below:
Total fluor area(sq. B.) _ ___-"_(including garage. Iinishad basement attics,decks or porch)
Gross living area I sq. It.) � __ Habitable room count
\umber oflircplaics___ ``{ NLmberofbedrooms __...
iNumher of bathrooms ._ .Number of half hathu
I')pe o(he�ting i)itemt Numher of decks: porches
i
i. "11ua1 Project Square Footage-maN he substinned fir•`focal Pr�jcct Cost'
CITY OF S.UI E.ti[
PUBLIC PROPERTY
DEPARTMENT
a, uuur arsu�u
wroe i>o v.oWOOMM A..ar•sera MANAO&MM 01f-s
run.+-t`r+s.ssrs• K..s r.s.7+e.ow
HOMEOWNER LICENSE EXE.MMON
Ptease "I
Dare 20 t I 1
Job Iocatlas �Q$on S�-ree f
Home Owner Address S
Home Owner Telopbone G7 8 '7 . -Z 21'
Present Mailing Address Sr �
no current exemption of"Homeowners"was extended to include ownw-occupied
dwellings of two Units or tea and to allow such homeowners to engage an individual for
hire who.does not possess a lieenso provided that the owner seta as supervisor.
DE INMON OF HOMEOWNER
Person(s) who owns a parcel of load on which he/she resides or intends to resider 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 structure. A pawn who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"twmeowner'shall submit to the Building Official,on a form acceptable to the Building
Oflicial, that he/she be resporuiblo for all such work performed under the Building
PermiR
The undersigned "honseownse assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undenigned "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 r rements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDNG NSPECTOR
See other side for state code
CITY OF S,V-&Nfs AkSS,1C1-iC'SET"I-S
13CILDLNG OEP.1RT.%LLNr
I 20 WAS)I VGTON STXM, 3'O FZOOR
T�L (978) 743-9595
KI3®faRLt3Y ORLSCOLL FAX(970) 740.9846
.titAYOA THo-%(U ST.PMXjt4
DixEcrott OP PL SLIC PKOPEItTy/9LMnLN(;COJL11jSStONER
Constructloo Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CUR section I 11.5
Debris, and the provisions of MGL a 40, S 34;
11 Building Permit M is issued with the condition that the debris resulting from
work shall be disposed of in a properly
1 11, S I SOA. licensed waste disposal facility as dofincd by MGL c
The debris will be transported by:
---=— _
(n4me ot'Aeula )
The debris will be disposed of in :
(name of facility)
(Jddrasr orrj,: y)
44�I Orm'f PPl"Jltl -
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