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32 MASON ST - BUILDING INSPECTION (3) The Comm FF$ CITY OF Board of Build la an ar3s SALEM Vu, Massachusetts State ppBuilding 11Codee,7800�CMR Revised,Nur2011 Building Permit Application To(cl1�lttYtYf ReqaitrRetYovtOr Demolish a One-or Two-Family Divelling This Section For Official Use [BB,uilding Permit Number: Date A ds ' 1 4 i% ilding Otticial(Print Name). Signature- ' Date SECTION 1;SITE INFORMATION' ` . Property Address: 1.2 Assessors Dlap d'r Parcel Numbers 9 M�5n�i S� I A 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 Arca(sq 11) Frontage(11) 1.5 Building Setbacks(R) From Yard Side Yams Rear Yard Required Provided Required T 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?. Municipal❑ On site disposal system ❑ Public❑ Private❑ Check if es❑ P SECTIONZ: PROPERTYOWNERSHIPI' 2.1 Ownert of Record: Sff/P� Mom+ i1fm'�Prinl) City,State,ZIP ' llu(IO Zt��,• /� �/ Z �J , fillGr�C ✓i�sf/ 6vl No.mi mot Telephone GmaiI Addrcsg SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify: Brief Description of Proposed\Vork': 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 $ ❑Total Project Costs(item 6)x multiplier x 3. Plumbing $ ether Fees: S 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire i To All Fees:S Su ression) r Clieck No._Check Amount: Cash Amount:_ 6.Total Project Cast: S 2.5 co,0,0 ❑Paid in Full ❑Outstanding Balance Due: SECTION5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) , License Number Expiration Date Name of CSL[[older "'' I.r ' 'List CSL Type(see below) No.:md Street Type - - Description U Unrestricted(Buildings up to 35,000 cu. 11.) R Restricted I&2 FamilyDwelling City/Town,State,ZIP M Masonry RC RootingCovering 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 [IIC Company Name or HIC Registrant Name No.and Street Email address City/Town, State ZIP Telephone 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 Oft 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. /0 O Print Owner's Name(Electronic Signature) to SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION ' By entering my name below,)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. Y /It .o7lJ 4ILL Pnnt ner's or Authorized Agent's Name(Electronic Signature) Date NOTES: I. An Owner who obtains a building permit to do his/her own work,or anowner who hires an unregistered contractor (not registered in the Home Improvement Contractor(111C) Program),will liol have access to the arbitration program or guaranty fund under NI.G.L.c. 1 d2A.Other important information on the HIC Program can be found at 3eww.m:as.aov:10e1,Information on the Construction Supervisor License can be found at www.masso_ov:'JL . 2. When substantial work is planned,provide the information below: "total fluor area(sq. 11.) (including garage, finished basementlattics,decks or porch) Gross living area(sq. it.) 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. "Ibtal Project Square Footage"may be substituted fur"'fot:d Project Cost" C y OF SALE4 MASSAMUSEM {< } ; BUILDING DEPARTMENT 120 WASHNGTON STREET,3m FLooR 'ILL. (978)745-9595 KIMBERLEYDRISOC)U FAX(978)740-9846 MAYOR THomAS ST.PIERRE DIRECTOR OF PUBLICPROPERTY/BUILDING COM,wss ONER 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 c40, 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 deposit facility as defined by MGL c 111, S 150A. The debris will be transported by: .,ft6e(L. f Alm �Ao(P_•v�i►2�_ (name of hauler) The debris will be disposed of in: (name of facility) (address of facility) gnature of applicant Date CITY OF SALEM, MASSAalUSETTS l� BUILDINGDEPAR'I'NIENT 120 WASHINGTONSTREET,3"D FLOOR TEL. (978) 745-9595 FAX(978) 740-9846 KIIvIBERLEY DRISCOLL MAYOR TY-ION(AS STTIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: +,/ Date (19- © q- U \ Job Location 32 /YY!2aa ,/ $ t Home Owner Address 51 Present Mailing Address 3 M1150A/` 54 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 that does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s) 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" shall submit to the Building Official, on a farm 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 understand the City of Salem Building Department minimum inspection procedures and requirements and that he/she will comply with such procedures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING INSPECTOR —` "-