51 MEMORIAL DR - BUILDING INSPECTION (2) The Commonwealth of Massachusetts CITY
DF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code,780 CMR Revised Mor 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
V" One or Two-Family Dwelling
- Tkis$„calms for 10111oial Use .
t Buiding Forath Number : Date .plied:
be
l &uitdfngOtltciat(PrintName) :Stgnaiwc
SECTIONi.SM RIFORMATIOPI'
I— 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
ll S1 (V1fr+e.ria� Oftyt
1.1a Is this an accepted street?yes ✓ no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Requited Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage/Disposal System:
Public Ill"/ Private❑ Zone: _ Outside Floodne? Municipal® On site disposal system ❑
Check if yesIO
SECTION 2 PROPERTY 4'R NRSHiPt
2.1 "err of,,R�eecord.-
Kvlt Moor( Sal, /rIR plg7n
Name(Print) City,State,ZIP
51 ('AtrwerTol lalyt 17Y-7?3- oY41 1" Wld. (at
No.end Street Telephone Email Address
SECTION 8:DESCRIPTION OF PROPOSED WORK=(shack all that apply)
New Construction❑ Existing Building❑ On;—Occupied)( Repairs(s) ❑ 1 Aiteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed WmV, R e Sid c guic
SECTION 4:ESTIhli1TE)CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only .
(Labor and Materials
1.Building $ 1. Buildlng Permit]?eec$ Indicate how fee is detarmineck
❑Standard City/Town Application Fee
2.Electrical $ E)Total Projoct Costa(item 6)x multiplier x
3.Plumbing $ 2. Other Fees_ $
4.Mechanical (HVAC) $ '
5.Mechanical (Fire
Su ression $ Total All Fees:$
y oe o Check No. Cheep Amount: Cash Amount:
6.Total Project Cost: $ (�9v�► ❑Paid in Full 0 outstanding Balance Due: .. .
HNC 7D US-C-
r
SECTION 5: COY48TRUC MN SI�VICES !
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
Lis[CSL Type(see below)
No.and Street
U I Unrestricted(Buildings to 35,00 cu.ft.
R Restricted]&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covermit
WS Window and Sidimt
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town, State ZIP Telephone
SECTION 6:WORKERS'CONWEMAT14D N VWXRANM AFFIDAVIT(T►'LG:I, c.152.§ ?5C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Faihire to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No...........❑
7ae OWNM AUMOR ZA T6119 CO LETED WHEN
9WNER'S A OR C TQR IING.PI'I' .
I,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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b-OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Prin Own f 's or Authorized Agent's Name(Electronic Signature) Date
1. 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
MM.mass.gov/oca information on the Construction Supervisor License can be found at www.nmss.gov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
QT'Y OF SALEM, MASSACHUSE n S
BUILDING DEPARTMENT
\~ � 120 WASnNGTON STREET,3" FLOOR
TEL. (978)745-9595
KIMBERLEY DRISQDLL FAX(978)740-9846
MAYOR THOMAS ST.MERRE
DIRECTOR OF PUBLICPROPERTY/BUILDING CONZffSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date -7 h(, I
Job Location S� NL(Mo�inJ DJria o /em MA
Home Owner Address 51 N\e"r; j
Present Mailing Address_ 51 Nlenn.rr"� pr%ye
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 P y compliance with the State BuildingCode
e 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.
G'
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR
QTYOFS ALEM, MASSAQ3U5E77!
BrfDMiBirAFMMvr
120 WA9ffVW N SnWv 32D R OOR
1�L�978)7�5-9595.
FAx 74D-9M
SIA�ERIlYDRiSaDIL
MAYCR DICO SS7'.i' MM
Dnmcl ca cippuauibpxaFmY/Buumi Ga3wmcm
Construction Debris Disposa/Af rdavit
(required for all demolition and,-renovation work)
In accordance with the sixth edition of the State Building Cie, 780 OAR, Secdon 111.5 Debris,
and the provisions of MGL c40,S 54; Building Permit B 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 ill, S 156A.
The debris will be transported by:
/' 1UI cl nfios�r(name of hauler)
The debris will be disposed
po of in:
(�or4ln.srd e �frn�
(name of facility)
(address of facility) '
Signature of applicant
7
Date