5 MEADOW ST - BUILDING INSPECTION GIThe Commonwealth of Missachuscits Town of
Board of Building Regulations ind StandardsJa
�
Massachusetts Stale Building Code, 780 CMR. 7'4 editionudding Dept
Budding Permit Application To Construct. Repair. Renovate Or De
One- or ruo•Funult Osrvlbng
This Section r Official Use Only
Building Permit Number Date Applied: Z 6
Signature:
z e
Buddin ornmissioneri In uildmp Dots
S TION 1: SITE INFORMATION
1.1 o A dres�:C I
1.I a Is this an ace teal street'.syea no I.2 Assessors Map At Parcel Numbers
Map Number Parcel Number
1J Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Awn(sq 0) Frontage(R)
1.5 Building Setbacks(it)
Front Yard Side Yards Rem Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40,154) 1.7 Flood Zoe*Information: 1.8 Sewsp Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Public O Private O Check if wito
SECTION 2: PROPERTY OWNERSHIP'
2, r worn f Berlin � I
"� �; I�_ M
a i) Aifdreu for service:
Si azure Telephone
SECTION J: DESCRIPTION OF PROPOSED WORKS(cheek ad that apply)
New Construction O Existing Building O Owner-Occupied O Repairs(s) O I Alteration(s) O Addition O
Demolition (3 Accessory Bldg.O Number of Units_ I Other O Speeiry:
Brief Description of Proposed Work': a G
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Offlcla) Use Only
Item Labor and Materials
1. Building f 1. Building Permit Fee: f Indicate how fee is determined:
O Standard City/Town Application Fee
2 Electrical S O Total Project Cost'41tem 6)x multiplier x
J Plumbing S 2. Other Fees: f
4. Mechanical (HVAC) S List:
s Mechanical (Fire S Total All Fea: f Ii0
Su resuon
I Check No. he Amount: Cash Amount:
n Total Project Cost f '/ (j1/� 0 Paid m full O Outstanding Balance Duc
1
u.
SECTION 3: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor ICSL)
License.Number Evpoation Dale
N,ype of CSL- Ilpldler L,st CSL Type tvcc below)
Address ID
Desch Ion
Unrestncted u to)5.000 Cu. Fi,
Restiorrcd Id2 Famd Owelrn
slisrulure S1a ResidTelephone Residential Wendow and S,dmResidential Solid Fuel Burnet A lance Installation
Residential Demolition
3.2 Registered Home Improvement Contractor IHIC)
HIC Company Name m HIC Registrant Name Registration Number
Address
Eapirahon Date
Sijpolure Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. ISL 123C(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.......... O No........... O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
f, as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application.
signature of Owner Data
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
1, e-3car-H r i d Ill as Owner or Authorized Agent hereby declare
that the statements apAinformilition on the foregoing application are true and accurate, to the best of my knowledge and
be r (r '
Sign of Owner or Au orized Agent Dam
(Signedunder the gains and Penalties of
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who him an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program), will W have access to the arbitration
program or guaranty fund under M.G.L. c. 1 d2A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations I IO.R6 and I IO.RJ,respectively.
2. When substantial work is planned,provide the information below-
Total floors area(Sq. Ft.) lincluding garage. finished basemenUanics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces - Vumber of bedrooms
Number of bathrooms Number of half.baths
Type of heating system Number of decks/ porches
Tvpeof cooling system Enclosed Open
1 "Total Project Square Footage"may he substituted for 'Total Project Cost"
•_s CITY OF SALEM
PUBLIC PROPRERTY
r� DEPARTMENT
J%WN ., Kew ,
It 120 W.%I]I%(.;ON S INLET •S.%I 1`.%f, �t.Ni.\l IIl H t I+:I a
I.Et.979.743.9;95 . Psx:979.743-983 e
Construction Debris Disposal Affldavit
(required fur 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 It _ is issued with the condition that the debris resulting from
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:
x �2S�4t�
(na c 'hauler)
The debris will be disposed of in
(name of army) ,
(address of facility)
signalu&Aff penrtat upp cant
' date
CITY OF SM.E.NI
PUBLIC PROPERTY
DEPARTIMENT
w,�yazr oae�a><L
sans o»-o
Nwrw 130 a• aM lnesr�sura<we,.aeoa
TsL 9'S-745-7s" •r•.a 9�L�+a9sw
HOMEOWNER LICENSE EXE.MMON
Please Print
Date JLI
Job Location ,
Home Owner Address
Home Owner Telephone -
Present
The currentl�i t exemption of"Homeowners"was extended to include ownesr-Occupieed
dwellings of two Units or Lena and to allow such homeowners to engage an individual for
hire who does not possess a license.Provided that the owner act@ as supervisor.
DEFWMON OF HOMEOWNER
Peson(s) who owns a parcel of lad 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 mWor 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 ®cial,on a rm underble to the the Building Building
ble for all
Official, that hd,he be responsible performed
Permit.
The undersigned "homeowner'assumes responsibility for compliance with the State
Code and other applicable by-laws and regulations.
Building
The undersigned "homeowner"certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that hedshe
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE '
.APPROVAL OF SUILDNG INSPECTOR
See other side for state code