103 MASON ST - BUILDING INSPECTION (3) Q ^ Fltc Conunomce:dth of Massachusetts �- - —
IIrg1'J of Building Regulations and Stand;ilds I'11K
I"LISSarhusCUS State Building Code, 7SO ('MR. 7"' edition
1 1 tit.
Building Permit Application To ('uncuuct. Repair. Renciiiate Or Denwli.h a
(hoc- (ir Tit'I)-Famih, l)%rrllirl,e Ifi8
_ 'I his Section For� Official Use Only ------i- I
Building Pei mil Nwnher Date applied: --�
BudJ.nig ununis,ioneri sprrlor of Bwldllll:l
i
SECTION 1: SITE INFORMA UION
1.1 Property address: 1.2 assessors Map & Parcel .Numbers ---- --- - -
I.1,1 Is this an aero:pled street 7 YC. no Nlap Nuinher P:u.el ,Numhvi
f.3 Zr,Ir±rreg Information: 1.4 Property Dimensions: �
— — - — - -
1.5
- I
Front Yard Side Yards Rear Yard
Reyu]led Provided Re cared ...- --I
4 PrnvWcd RCymred
I
1.6 Water Supply: i.N.G.I_c. 40. §511 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public L� Private❑ Zone: Outside Flood Zone? i
—__ Check it'yes❑ sIUn;c:pal ❑ On site disposal syslam ❑
I _ _ SF.CTION2: PROPERTYOWNEI:SHtPt !
F21'.I wneF of eco ----------- ---- '
C.
Address tier Service
�Signature _. I Telephone .-----.—-
- - SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Can n ron ❑ Existing f)ui!ding _i Owner-Occupied ❑ RCparsf sl Alierauun(sI I \JJ,r' n ❑
Demouuo.n ❑ Accessory Bldg. U Number of Units Other ❑ S it
--- p c y -- - -- — - --_�Brief Description :if Proposed Work' — — — -----
� e
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials) Official Use Only
-;
I. Building I. Building Permit Fee: $ Indicate haw fee a JrtnnnricJ:
'. Flectrical S� ❑ Standard City/Town Application Fee
❑ Total Project Cast' (Item 6) x multiplier
�. Plumbing Y '. Other Fees: $
- - i
J. Mechanical IHVAC) 'S List:-
-5. Mechimic:d (Fire ------
Su ) ression) y Total all Fees: S
_�� Cheek No. ('heck Amy-one
i e Total Project Cost 5 -- ------ --
❑ Paid in Full ❑ Outst:uldulg Balance Due:-- _--
SECTION 5: CONSTRUCTION SERVICES __-4
5.1 Licensed Cunstruclicool' Supervisor (CSI.)
01 C .. I.Iraue Nulnh..r 1`vplr.lnun D-11a
N.unc III CSL I folder Lut('SL 'rt lie (,cc hcloa l —----_
-ht, i, Drain �tion
\JJIc l l nrrstrn led iL,to };.wo Cu. PIS —�
R ReNlneted I&' Fanuh
SILn;aura 11 NLuonn Onk --i
RC Restd:nllal R uu l in cl otrinle ___.--1
— -- \\'S RraJ:nli.d \\l ndol, -wJ
r:lrphonr
]F Rea Jenuul SuhJ Purl Bwmile \ ,I li,lll_linl.il l.11n ni_
aJc midi Demolition _-----{
5.2 Registered llorne ltnproventent Contractor (IIICI
Regulrauun Nu usher
Ii IC C olltpally Nanle or PIIC RC_L'Islraltt Nallle
,\Jdros Faplration DILL:
Telephone
! LgratuIe
INSURANCE AFFIDAVIT (M.G.L. c. i52. 9 -3Ci6P)
SECTION 6: WORKERS' COMPENSATION
mmed with this applira(inn. F:inure w pnnlde
tWorkers Compensation Insurance affidavit must be completed and sub
his affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached'? Yes .......... ❑
No C1
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
p A r♦�/>C �, as Owner of the subject property herebv
to act on my behalf. in all maulers
authorize
relative nk au[horiz d by this buildin ermit application.
Date —
Si nawrc ul'Owner --il
SECTION 7b: O NER' OR AUTHORIZED AGENT DECLARATION
—�-
(r' 6' • as Owner or Authorized Agent hereby declare
II
he foegoing application are true and accurate, to the best of my knowledge and
that the statements and information on t
beC-- �
- -
_
ne- f��11
i
i s��nulllre,>� r�.Ir:4ulhoond.\gent � __�5ieneJ under the pains and penalties-of perjury
NOTES:
I. An Owner who obtains a building permit to Ju his/her own work.or an owner echo hires :ul unrcglNroled anura.lol
(nut registered in the Home Improvement Contractor(HIC'.PPntgruml, will ant hale access to melu hill al
program or guaranty fund under M.G.L. v. 1.1'_A. Other im urtant intoirrla(ion on the HI(' Pmg . ll .Ind
Construction Supervisor Licensing (CSL) can he titund m 780 C6{R Regulations I IO.RG and
1 IU 125, resprnncly
—When substantial work is planned, pn>v u1e the mfurmation below
ncluding garage. tinished hasentent/aincs. decks ur porch)
T,nal floors area ISq: 1:1.i ----- Hahnabte room count --_---- --
(irnss living area(Sq. Ft.l ----
Number of hcdntums
Number of tlteplaces -- Nu nber of halt/h.lth>
Number of bathrooms Number of deck./ pornccs
fspr of heating Nvsmm —
fspe of cooling N}Nlem —
i "Toed Project Square FooL•l"e• may be substituted tin Coial Pmlc"t Coat '
kchikoch Carpentry f"l- oject quote
978-524-,1823 Cell: 978-998-9167 This Quote Is Valid For 30 Days
12 Prince St. Apt. 2 Salem Ma 01970
TO DATE QUOTE NO.
ADDRESS PHONE NO. CUSTOMER PO NO.
Q '
LOCATION
\C'\1 103
START DATE FINISH DATE
CONTACT: t TERMS
Ca
777J Sobc�xF a 1
rc�cf� 1 S OU
11 Ho LIC h
l i rAmeciec r) C'm
Vinyl Shcnq �)7s Ov
(o (eoaC4rywof w1 i -�,o0 C)C)
d ruz,-.,j toso 00
TOTAL LABOR
TOTAL MATERIAL 3 3 13c7 co
CUSTOMER APPROVAL TOTAL MISCELLANEOUS
SIGNATURE t'I1� cx�
SUBTOTAL 3? 30 00
TAX I 1
AUTHORIZED SIGNATURE
SIGNATURE GRAND TOTAL
. y
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KIf1Y��rvw-n
MAYM 130 WxoaN .ZoM Sruar•Siu EK%&.%Acmuuns0t970
lmi 973-74S-959S*FAx.97L74&964 -
HOMEOWNER LICENSE EXEMPTION
•Y Please Print.
i
Date oG ( eD.
Job Location�jo � gl9 S� S (
Home Owner Address
Home Owner Telephone 9 7*— Ill o —cLfS�
Present Mailing Address s a t-V
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 dwellin& 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 form acceptable to the Building
OfftciA 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 minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements. �
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SALEM
t PUBLIC PROPRERTY
: ' ;i
DEPARTMENT
g�TNt v�%
'd ': u %,111%,,.,IN 1I R1 I T ♦ ).\I Im, M\',iA, :.. <i.I
17t ;78-7;;.9;9; • I ns: 778 74:984,
Construction Debris Disposal Affidavit
(required for all demolition and I-C11OVatiOn work)
In accordance ith the sixth edition of the State Building Code, 780 CMR section 1 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit ix _ is issued with the condition that the debris resulting front
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
I 11. S 150A.
The debris will be transported by:
i
(tame of hauler)
The debris will be disposed ot'in
(name ul facility)
(address of facility)
---- . .signature of permit applicant
— date - -- --