23 MASON ST - BUILDING INSPECTION (2) I� The Commonwealth of Massachusetts Town of
(� Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 7'a edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Tit o-Fanuls Du elling
This Section For Official Use Only
Building Permit Num Date Applied: i 0
Signature: ` s
In uildin s Date
�( 1—Sf
Bud g Commissioner/ 8
ION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Percel Numbers
f0/1
I.1 a Is this an accepted street?yes no Map Number Parcel Number
:d
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use La Arcs(sq R) Frontage(R)
13 Building Setbacks(D)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Munici al❑ On site dis sal s stem ❑
Public O Private❑ Cheek if s❑ D Do y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
XName(Print) Address for Service:
Signature Telephone
SECTION l: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(a) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Speciry:
Brief Description of Proposed Work': 0001,—
_ j
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building S I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2 Elecincat S ❑Total Project Cost'(Item 6)x multiplier x
). Plumbing S 2. Other Fees: S �
4. .Mechanical IHVAC) S List:
s Mechanical (Fire S pq®AO Total All Fees: S
Su ression iJ
Check No. _Check Amount: Cash Amount:_
6 Total Project Cost. S ❑ Paid in Full 13 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Super%isor(CSL)
/✓P�w L,cvnx Numbr Espuuuon Date
N,4roe„tCSL Iiplder J ] List CSL Type(.ee below)
T thscn non
Address
U Unrestrrcted u to)),000 Cu. Ft.
R Restnctrd I&2 Fared Dw elfin
'ignature M Mason Only
RC Residential Roofin Covering
Telephone wS Residential Window an'Siding
SF Residential Solid Fuel Bumin A liantt Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
r \ Address
Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.1 2SC(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. _
Sighed Affidavit Attached? Yes ..........O No........... O
SECTION 7s: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.
r(Siumdunder
Owner Date
SECTION 7b:OWNEWOR AUTHORIZED AGENT DECLARATION
�1 as Owner or Authorized Agent hereby declare
men foa ion on the foregoing application are true and accurate,to the best of my knowledge and
ner or Authorized Agent Date
the pains and penalties ofperjury)
NOTES:
I. An Owner w blains 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 nyj 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 780 CMR Regulations I IO.R6 and 110.RS, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) I including garage. finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of rpreplaces Number of bedrooms
Number of bathrooms Number of halfbaths
Tvpe of heating system Number of decks/porches
Ty pe of cooling system Enclosed Open
' Total Pro)ect Square Footage"may he substituted for 'Total Pro)ect Cost"
CITY OF SMY.Nt
PUBLIC PROPERTY
DEPARTMENT
Mwraa 130 WASUPWU M STUM•&UM VAUAORscrts 019-0
Tti1.976-745-7s99 •FAx 978-7+0-704
HOMEOWNER LICENSE EXE.MMON
Please lrlrat
Date
Job Location 3 lgso v1 J
Home Owner Address
Home owner Telephone 16 1 — — 36 z
Present Mailing Address j4.!ae
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 who does not possess a license.provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Persons) 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"shaH 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 understands the City of Salem
Building Department minimurn inspection procedures and requirements and that he/she
will comply with said procedures and M
ents._
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDNG LrSPECTOR
See other side for state code
_ - i
CITY OF SALEM
� i PUBLIC PROPRERTY
DEPARTMENT
4 aM P%
M`,1 tl< 120 WAS II\'t::ON$TItEJET•SA I N11.`t.\ii:\t'.I It it I'i i JI`L�:
TE1:978-745-9;95 • pss:978.7449846
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 M _._ is issued with the condition that the debris resulting from
waste disposal facility as defined b MGL c
this work shall he disposed of in a properly licensed I y Y.
111. S 150A.
The debris will be transported by:
�n �� �ZnQa141
(name of hauler) 'A
The debris willbe disposed of in
>°LBC Jtv\
(name of face rt
(address of facility)
signature of lxnnit applicant
r— cr)f
date