60 MASON ST - BUILDING INSPECTION _. ---
The Commonwealth ul I%9as,,trL•usctts
O t _ Board of Building Regulations and Standards ht}It
"' Alt Alt u' \I rI Y
Massachusetts State Building ('ode. 7S0 ('!�1R. 7 edition
' Building Permit ,\pplication To COIISIrnCI. Repair. Reno%ate Or I)rnx,lish a R, t,rd Lrrur,r, r
thu•- Nr' Tlru-Frunih D,rrlliit,t
',n r.\
T is Section For Official Use Only
Bull ine Permit Numb c Date .applied: �� -
r lI
St.-,[[
Buddu g Coimms.ronari Inspeenrr of Buddoigs Date
SECTION I: SITE INFORMATION
k I.1 P , e•eW \ ess: �'"1 1.2 Assessors .Ylap & Parcel Numbers-----^- - -
Ma Number Par.cl N�Uillher
I.Lt I. Ih;; ,;n accepted strcr[. yes_ no--- _p_ —__—_ ---i
r, - 1.4 Pro ertY I�,irneic.iuns:
,.+ s_uning information: P .
�naa District 'rrupu .t I-I;,t - - Cu (su It) El urnegc Irii —
1.5 Building Setback: (ft)
Frnnt Yard Side Yards Rear Yarn
! Rrynhed 'Provided Rr,wrad Provided Recoiled
I
1,6 1i'ater Supl+iy: IY1.G.L c. 10. §5!) Lune: Outside Flood Zone:'
l.7 ri<:ud Zone Information: 1_8 Sewage Dispos..7 System:
Puhfc 0 Private[3 — Municipal ❑ On ,ill disputia! s}snan ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owne 'of Record: C�
.N Print) .address for Service:
SECTION 3: DESCr.IF• ION OF :•RO:rOSED WORK'(careck all that apply) Adjhr___
Vew Conarucao , C .isong Builu n Owns Jc.0 : cr' Y.epan :+s) ❑ 1 \.,eras r.
Demoliti;;. ❑ I Accci,,ory Bldg ❑ —I,Number of Units-_-�Z- Other 0 Spc�r.y ----- __'
� trier sc rhuon of Pr.>pI .•r-_
IF
--
SECTION J: ESTIN VTED CONSTRUC 1 t N CO.-ITS
Estimated Costs:
I Official Use Only
I Item tLahor and Materials) O
� Y
I. Building $
I. Building Permit Fee: $--- Indicate hum fee is derci a urcd:
— ❑ Standard City/Town Application Poe
Electrical S
'I']oral Project Cost' (Item G) s multiplier s _
i
3. Plumbing S '. Other Fees: 'S
4-. McLhamcal (HVAC) 'S List:
i
j. Mechanical (Fire $
Su , ression) Total All Fees: $_ - --
Check No. __Check Arri-call _ ('ash \nc,nun:
j b -rota) Project Cost 's 4��• ❑ Paid )n Full ❑ Outst.)rrdmg B:d:u;rr Uua:___ ___.
SECTION 5: CONSTRUCTION SERVICES _
5.1 Licensed Cunstractimt Supervisor(C'SI') 9
f_i.cn,c Numher _—_ I`.,pir.nu�n D.11
Name oitfjCSL- I loj cr
I.i,t CSI. I\lie i,cc helt,l,1
I _ .� 'fv c Dc,eri non
\JJrr
- l Cnrc,)nr)rJ kill to 3?.(9)0('u FI 1
- — R Restricted L@2 F.mnh D,tel6ne
Sienauu • \1 S1a,onn Unh
/}dry —J
RC Rc,idcnnal Rt.,.line l'u,::in`.
feicplume \1'S Kc�iJnui,il Nlndu„ .mJ ]cline ____
SF Re'IJenn.11 S)Ld fuel liw nme \)ppli_in In.(_d Li0n'.i5_J
D Rc.iJcnli,J Uenwl m,m
5.2 Registered Horne Improvement Contractor (IIIC) -- ---�{
I41C C)n pany .Name or HIC Registrant Name - Regi,trauun Numhcr .._
Addres.,
Eaprawm Date
SECTION 6: WORKERS' CONIPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 25C(6))
'Workers Compensation Insurance affidavit must be completed and submitted with this: application. Failure it, pro,ide
Ihis affidavit will result in the denial of the Issuance of the building permit.
Si"ned Affidavit Attached? Yes .......... ❑ No .......... ❑
SECTION 7a: 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 ; ll marten
relative to wotk authorized by this building permit application.
Signature of Owner ate
S TION 7b: OW ERn OR A HORI 'D AGENT DECLARATION
)• Owner or Authorized Agent hereby declare
X fha e Staten nts and information on the foregoing application are true and accurate. to the best of my knowledge:and
hchaff.
Print Name
S rM
ner i: .AuthenzcJ Ar,•^+ Da•c
e inns and enalties of erju ) NOTES:who)brains a building permit to do his/her own ssork, or anowner who hires an unke�a,lered contra,.nnred in the Hume Improvement ContractorIHIC) Program), will not have acres; to Inc arbitration
guaranty fund under M.O.L. c. 142A. Other important information on the HIC Pru,traim Supervisor Licensing (CSL) can be found in 780(TIR Regulations 1 I0.R6 and 110.RS. rrspectnelyit
When ,ubmantial work is planned, provide the information below:
F)tul flours area ISq. Ft.I imcludmg garage, fini,hed basement/a(tics. decks or porehi
(lros.s living area ISq. Ft.) Habitable room count
Number of fireplaces Number (it hedrtanns
Number of hathr)trns Nnnber of halt/ha)h,
l\pc of heating ,v,(em -- _-- Number of decks/ porehcs -- ----__,_---- _,
Type ofcoohng system _-
3 ..Toed Project Square Footage- may be subsuwrcd for Lotal Project Co,l- f
CITY OF S.'t y. m
PUBLIC PROPERTY
DEPARTMENT
VAYM - .. 130wAouNcrewsmasr•SAu!Km- As&Acm;= rso1970
TM-TW704S"•FAX.97L7i0.96M
HOMEOWNER LICENSE EXEMPTION
Plea"Print
Date [101
�s � _ /J
Job Location /`" 07-
��
Home Owner Address O .f//v56Y7 f
Home Owe Telephone -F- $20
Present Mailing Address loD �/Ag67'1
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Unite 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
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 foam 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 understanjs the City of Salem
Building Department minimum inspection rocedtres an uiremrn and ,hat h she
will comply with said procedures and ui eats.
HOMEOWNERS SIGNATURE m
APPROVAL OF BUILDING INSPECTOR
See other side for state code
. S", CITY OF SALEM
.> y
R1 PUBLIC PROPRERTY
DEPARTivIENT
I'.I i'. F:I:'1 •I:Pu i :I
SI "! L'CV.\A11\i—,'N'1f1:1:IT # ".\II\I. MAli\k .!1 :I I !':1'1
1-1:1. 9-8--0-9;95 # I'\S:978 -a ')531i
Construction Debris Disposal Allidavit
(rcyuited for all demolition and renovation work)
In accordance \6th the sixth edition of the State Building Code, 750 CNIR section 1 1 1.5
Debtis, and the provisions of NIGL c 40, S 54;
Building Permit H - is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name of.hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
-- . -¢nature or permit applicant
v 0