40 MEMORIAL DR - BUILDING INSPECTION (2) Y �
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
'Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
IW't Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
This Section For Official Use
Building Permit Number: ['Date,A
Building Official(Print Name) . gnat _ Date
fSECTION I:SITE [NF r AX ON
L
erty Address: 1.2 Assessors Map& Parcel Numbers
o PI�l0 this an accepted street'?yes no Map Number Parcel Number
ning Information: 1.4 Property Dimensions:
District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public ❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yesO
SECTION 2 PROPER Y OyYNERSHIPL ':
2. Ownert f Record: (/
Name nt) Ciry, ate,ZIP N�rA L ( �t, /y
yd/7��7O.1�AL .bP 8 4V9
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF.PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Cl I Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ erofUnits Other ❑ Specify:
Brief Description of Proposed Work': )
7'wa
SECTION 4: ESTIMATED CONSSTRUCTION COSTS-
Estimated Costs: Official Use Only
Labor and Materials
1. Building S I. Building Permit Fee:S ' Indicate how fee is determined:
2. Electrical
Standaid..City/Town Application Fee
$ ❑'rota\Project Cost3(Item.6)x multiplier x
ELT S 2. Other Fees: 3
I. 4lechanical (tlV:AC) S List
5. Mech'Ilmil (Fire $
Sri r trc— nr) _ -- 'total All Fees: .S-
Check No. Chcck Amount: Cash Amount:
s l'„tat P
roject Cost: S G ,SOO ❑ I'ai,l in 1'nll ❑ outstanding Ilalmtcc Ihw:
- - - __ -_...------------ ------------- ----- -
I
SECTION 5: CONs'rRUCI'ION SERVICES
5.1 Construction Supervisor License (CSL)
Licensz Number Gepinttimt Date
Name of CSL I lolder
List CSL'rype(see below)
Type Description
Nu. anJ Street
U Unrestricted DuilJin s u to Ji,000 w. R.
R Restricted 13c2 Fnmil Dtvzllin
City/gown,State,LIP M p-lasonr
RC Refill Coverin
WS Window and Sidin,
SF Solid Fuel [laming Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
H[C Registration Number Expiration Date
I IIC Company Name or MC 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 OR CONTRACTOR APPLIES FOR BUILDING PERMIT
=behalf,
bject property,hereby authorize
n all matters relative to work authorized by this building permit application.
lectronic Signature) Date
SECTION 7h: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, [ hereby attest under the pains and penalties of perjury that all of the information
contained ' is application is true and accur, a the best of my knowledge and understanding.
- �3
Print Ott,ntr's or Authorized A, n t toe' um• ignature) t
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an 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 M.G.L. c. 142A. Other important information on the HIC Program can be found at
www m;tss.euvioca Information on the Construction Supervisor License can be found at tvwtv.mas.eo�4IL
2 When substantial work is planned,provide the information below:
total floor area(sq. ft.) (including garage, finished basement/attics, decks or porch)
tiro;; living area(s(1. d.) _ Habitable room Count —
Ntimberoftll'epl.teci_-.--_----- Number of bedrooms
Number of bathnwms _- ___ Numher of halEbaths
--------- --
1'vpe of he:uiug sy,leitt
I",pe of cooling iyQel❑
1. "1",11d1 Ploj:rl Oyu uv Lead i O" m:ty be sub;tinitrd Ini ["(A Plojert foal ' _ . .
bar .
Y
CITY OF S.Uzm, LtiLks&wHUSETTS
1,. BL'tLDLvG OEP.1RTJONr
I20 1(/.\SFfLNGTON STREET, V FLOOR
TEL (973) 745-9595
F.�X(973) 7.40-9344
:<!J[t3ERL.HY DRlSCOLf.
,bL�YOa DI016\S ST.PIERIM
DI:tECCOR OF PLOUC PROPERTY/BCILOLYG CO3L\(15SIO.iER
Construction Debris Disposal Affidavit '
(required for all demolition and renovation work)
fn accordance with the sixth edition of the State Building Coda, 730 Ch1R section l t 1.5
Debris, and the provisions of ab1GL c 40, S 54;
Building Permit fE is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed wasta disposal facility as defined by,�IGL c
111, S I50A.
The debris will be transported by:
(name ul'hauter)
2
The debris will be disposed of in
(manic or racility)
—_—_—0111"J, ur radially)
signature of Pc plicant
-.d_f` 1S' zo,
I
CITY OF SM-EM
a, PUBLIC PROPERTY
DEPARTMENT
V 111WfY Nwr• r L
wva
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nL srsns ast .v.a rlVr+o ow
HOMEOWNER LICENSE E.Xj.m"j0,V
Pin" Mae
Date�r�g� fj
40
Home Owner Addressa`�M D�211�L Ul7 SA •`iL _ ��
.�
mom Owner Telephone
Pm ud Mailing Address 0
A"454 L s}— <TA47
Tie currow exemption of"Homeowners"was estmded to include owner-<"ied
dweuiags of two Units or fear and to allow such homeowners to=gala an individual for
him wbo.does act poaaese a Ilceew`provided that the owner seta M aupwWs w.
DFYINMON O/HohaoWNMt
Person(s) who owns a Pavel otlaad on which WAS raotdas err intends to reside, o0
which them i� or is intended to bq,a one or two rawly dweWag, attached or detached
awcturee Accessory to such use and/or firm uruotures. A person who comttucte more
than one home in a two year period shall not be considered a homeowner. Such
"Homeowner''shall submit to the Building Oillcial,on A form Acceptable to the Building
Permit
Otlldsl, than hdshe be respansib►e for all such work performed under the Building
The undersigned "homeowner"Assumes responsibility for compliance with the State
Building Code and other applicable bylaws and reeu►adona,
The undenigrsed "hcnseownce cer fits that hdahe undentands the City of Salem
Building Department minimum inspection procedures and requirements and that hdshe
vill comply with said procedures and requirement&
HOMEOWNERS SIGMA MRS
kPPROVAL OF BU/LONG OiSPECTOR
See other side for state code