9 MAY ST - BUILDING INSPECTION )n - I4- 1 $ 20IZQo �0�
The Commonwealth of Massachusetts RECEIVEQ CITY OF
W
Board of Building Regulations and StINVOCTIONAL SERV CES SALEM Massachusetts State Building Code, 780 CNIR Revised blur 2011
Building Permit Application To Construct, Repair, RenM4Mg13 0lA a% 3S
One-or Two-Family Dwelling
This Section For Official Use Only '
Building Permit Number. Date.A p ' d
1r a i
Building Ofl)cial(Print N:rne). Signature* Date
SECTION 1:SITE INFORrNIATION`
1.1 P erty Add 1.2 Assessors blap& Parcel Numbers
�� I�''(4"VI ��q3v
1.I a Is this an for tedati street?yes no Map Number Parcel Number
06
1.3 'Coning Information: LJ Property Dimensions:
"Coning District Proposed Use Lot Area(sq R) Frontage(It)
' 1.5 BuildingSetbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L a 40,§54) 1.7 Flood Zone Information: 1.9 Sewage Disposal System:
Public❑ Private O Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Check if es❑
SECTION: PROPERTY OWNERSHIP!'
2.1 Ownerl of Record,✓ (� p yt orA
�me(Print) f9
City.State--�ZIP
Nu� IiilC� S� faP� ll Z77-8a�� rylt? _(O'A&1 � 4,oa,C�ir-
d 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:
Grief Description of Proposed Work2: 16 ^eva &I
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Ilan Estimated Costs: Official Use Only
Labo�r}and Materials)
I. Building S D 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical 5 I s00 ❑Total Project Cost?(Item 6)x multiplier x
3. Plumbing S '. OOO !,PtherFees: S
d. Mechanical (HVAC) $ List:
3. Mechanical (Fire S Total All Fees:S
Su ressiun)
Check No. CbeckAmount: Cash Amount:
6. 'f utal Project Cos[: .5 I �O� ❑paid in Full ❑Oulstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Cmtstruction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL'rype(see below)
Type - - Description
No. amd Street
U Unrestricted(Buildings Lip to 35,000 cu. 11.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Rooting Covering
1VS Window and Sidin
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Ernail address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
I IIC Cuntp;my Name or IIIC Registrant Name
No. and Street Email address
City/Town, State ZIP Telephone
SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G.L C. 152.¢ 25.CM)..
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Ishuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No...........❑
SECTION 7a:OWNER AUTHORIZATIONTO BE COMPLETED W HEN.' :-
OWNER'S AGENT OR CONTRACTORAP PLIES FOR BUILDING PERMIT
1,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 Nmne(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
con t th7Zis ap ion is true and accurate to the best of my knowledge and understanding.
tail .
I 6
Prii er's or Authorized Agent's Name(E onic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or art 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 NI.G.L.c. 142A.Other important information on the HIC Program can be found at
1cww.mass.uov'oca Information on the Construction Supervisor License can be found at wwtv.mass.to��'dns _
2. When substantial work is planned,provide the information below:
Total floor area(sq. R.) `" .(including garage, finished basementlattics,decks or porch)
Gross living area(sq. R.) - Habitable room coma
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
rype of heating system Number of decks/porches
Type of cooling system Enclosed Open_
3. "Total Project Square Foolage" may be substituted fix"Total Project Cost"
CITY OF SALEM, MASSACHUSEM
Ji BUILDING DEPARTMENT
\ $ 120WASHINGTON STREET,3ADFLOOR
TEL. (978)745-9595
KIMBERLEYDRISCOLL FAX(978)740-9846
MAYOR THomAs ST.PIERRE
DIRECTOR OF PUBLIC PROPERTy/BUILDING CONAUSSIONER
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:
00k w uon � ( S)
(name of haul r)
The debris will be disposed of in:
(name of facility)
(address of facility)
6 t u rea of a plicant
Date
QTY OF SALEM, MASSAC HUSETTS
{i BUILDING DEPARTNMNT
'ly_ f jr v'i 120 WASFUNGTON STREET,3"D FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KIINIBERLEY DRISCOLL
MAYOR TrIOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date
11114114
p ,�n (� �^ rn ��.
Job Location l 0401, Lk
X�1,W/t'1(�I�""''(�' /a,��/�
Home Owner Address l �I (1/� y'y�,�V
Present Mailing Address 1 J ✓ rGLW't ►"v'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 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 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 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
J