25 MASON ST - BUILDING INSPECTION (2) J
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The Commonwealth of Massachusetts CITY OF
VA
Board of Building Regulations and Standards SALENI
Massachusetts State Building Code, 780 CMR
Revised.11ar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Fondly Divelling
This Section For Official Use Only
Building Permit Number: ate lie
Alding 01Pcial(Print Narn') Si ature - Date
SECTION I:SITE INFORI IATION
14/P rty A�jdress: 1.2 Assessors Map& Parcel Numbers
1.[a 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 11) 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 ifyes❑ Municipal❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Own r of ICcord:
-- y��v J��/r- ��e��G� CiA `ems
N4unc(Print) 'City, tate,ZIP
'No. mid Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK](check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work-:
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item (Labor
Costs: Official Use Only
Labor and Materials)
1. Building S 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
?. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 7. Other Fees: S
d. \lechanical (FIVAC) S List:
5. 1"echanical (Fire
Su ression) Total All Fees:$
Check No._Check Amount: Cash Amount:
6. Total Project Cost IS �V V O'0 0 ❑ Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL'rype(see below)
No. and Streetrype , Description
U Unrestricted Buildin s LID to 35,000 cu. It.)
R Restricted 1&2 Family Dwelling
Cityfrown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
'relc hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Comparly Name or HIC Registrant Name
No. and Street Email address
City/Town,State,ZIP 'rele hone
SECTION 6:WORKERS'CONIPENSATION INSURANCE AFFIDAVIT(NI.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
t9 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: OWNFW OR AUTHORIZED AGENT DECI ARATION-
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contra ed in this application is true and accurate to the best of my knowledge and understanding.
P It I), or Awed Agent's�uonic 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 tMLG.L.c. I42A.Other important information on the HIC Program can be found at
www.rnass.,ov:'oca Information on the Construction Supervisor License can be found at www.mass.gov lPs
2. When substantial work is planned,provide the information below:
Total floor area(sq. ttJ (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 healing system Number of decks/porches
"rype of cooling system Enclosed Open
3. "total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF S.U-Em
PUHIIC PROPERTY
DEPARTILF..NT
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Mi.f'f1119tf! 078,74964
HOIKEOWNER LICLNSB E.YE.M"j0►V
Pita" Print
Date Sec T 2 4� -2
iob Location S /�/ri so yr Sr
Home Owner Address
Horns Owner Telophions c,!
Ptesd Madbig Addrw
The current exemption of"Homeowners"was a:tended to inehWe owner-occupied
dwelfinas of twro Units or less and to allow such homeowners to impgo an individual ror
him wbo dos not poateas n tieenso provided that the owner acts>r or
auparvis
DEFINMON OF HORaOWM
Patrsoo(s) who owns a pared of land on which blobs rtxldes or Intends to reWde, on
which there i; of Is intended to be, a one or two !firmly dwaWng attached or detached
atructtues accessory to slash use as WOr 12rm atnacturea A parson who constructs more
than one home in a two year period IW rot be considered a homeowner. Such
"homeown essf'shait submit to the Building OQfeial, on s form acceptable to the Building
Permit that hdshe be responsible rot all such work performed under the Building
ne undersigned "bomeownes'asstuaes responsibility for compliarsee with the State
Buildin f Code sad other applicable bylaws and rettrladoaa
i7se undersigned "homeowner'cerddes that hdrhs undentands the City of Salem
GWIdin f Department minimum i
don rir►a Procedures and «quirrrrtrnts and that he/ths
,vill comply with laid procedures and requir rntz
HOMEOWNERS SIGMA M'M
kPPROV,AL OF aU/LD .va LV ECrOR
Sca athcr lids rat state cods
CITY OF SALEM, tiLksSACHUSETTS
BumD=DEP.xR-nLE2NT
+ 130 W.NSHLNGTON STREET, 3i'FLOOR
T EL (978) 745-9595
FAx(978) 740-9846
KlStBFRT F-Y DRlscou
tiiAYOlt T'HOSL►sST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/3MCING CON IISSIONER
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.
"fhe debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit appli nt
date
debris,I(dx