58 MEMORIAL DR - BUILDING INSPECTION (3) >
C'olnntonwealth of MaSSuChUSCIIS
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 730 CNIR SALLA11
Building Permit Application To Construct, Repair. Renovate r Dent s a
One- or Tu o-Family Dtrrlling \
this Section Fo 'fieial Use Onl
Building Permit Number. Date Applied:
Building Official(Print N:une)
Signature Dutc
SECTION l:SITE INFORMATION
L I Pro rty dress: 1.2 Assessors Map& Parcel Number
�k MAd�,uo,e .q l �_
I.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions,
Zoning District Proposed Ue Lot Area(Nq 11) Frmnluge(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.- Water Supply:(M.G.1.c.40,§5a) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public a Priv ate❑ Zone: _ Outside Flood Luna?
Check it es❑ Municipal�L On site Jispuwl system ❑
SECTION2: PROPERTYOWNERSHIPt
2 -O.wnerl o/Reid:
�.� /J ,rlilet/
Nm1( \ne((Print) n L fly.State,/.IP j
No.and Strcct 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:
Brief Description of Proposed Work=: t4 oo r
SECTION 4: ESTIMATED CONSTRUCTION COSTS
hem Estimated Costs:
(Labor and .Materials) Official Use Only
I. Building S I. Building Permit Fee: E Indicate how fee is determined:
2. Electrical g ❑Standard City/Town Application Fee
❑Total Project Cost(Item mu 6)x multiplier .x
3. Plumbing S
_. Other Fees: S
4. Mech;mical 111\':\(') S Lisl:
5. \lechanical (Fire —..- --------- ----- -'
Suppression) S Total :%it Fees: ------ -
o. Total Project Cost S Check No. _.—('heck amount: _ --- Cash amount:
000 ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: C'ONSTRUCrION SERVICES
5.1 Construction Su nervisor Lt•Cn ie(USIA
r 5 License Number I qri ration Dale
VY-
-- — -- ----
N'anrc nfirldcr
List C'Si.1)pe I+ce below)
_ f�j✓Y✓L1/�iuJ_ ✓-�'-_-- ------"._---- "fyPr• Description
No. and Street
"q U t hrestricteJ 1 Buildin,s LIP to 33,0110 eu. Il.)
mJV /d// __� "__ R Restricted I r2 Family Dwelling
Citcifoan,.State.LlP M1I Nlasoillry
RC Roolin g C'ovcrin
.. R'S Window and Siding
SF Solid Fuel Burning Appliances
y0121' 1 Insulation
'I'de hone hmail address D Demolition
5.2 Registered Home Improve tent Contractor(HIC) �y >6�� as
y)/JP,� �� �j � ,olS f Gt � / ✓Q/(l P/L IIIC' Rcgtstratiun Numlxr lispirutiun Date
IIIC'C^'yy�tyylpony Nune or I IIC'Registrant Nano
/�i✓F.2.✓Pry �✓� _
N!.�tStrect Email address
i�14�✓✓��S �7�S�a 5dy
City/Town.State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 15C(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 7u OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,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: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
contained in this ap cat' is true and accurate to the best of my knowledge and understanding.
Print oa cr's ur Atilhorized Age I's Name I lilcctronic.Signature) Dale
NOTES:
I. :\n Owner who obtains a building permit to do his,her own work,or an owner who hires an unregistered contractor
Inot registered in the Home Improvement Contractor(HIC) Program),will! have access to the arbitration
program or guaranty fund under M.G.L.c. 112A.Other important information on the HIC Program can be found at
wue m.i,. n , .1 Information on the Construction Supervisor License can be found at dp,
2. When substantial work is planned,pros ide the information below:
Total flour area Isq. R.) _ I including garage, finished basentcnt'attics,decks or porch)
truss living area I sq. Il,l _ - Habitable room count
\'umber of tirCplacu Number of bedrooms
Number of bathrooms _ \umber of half h,ulns
I\pc of heatutg iutcnn _ ... . -. .._ Number of decks, porches _
I 1 PC of cooling >)stun - Inclosed - _ Open
I. ,:1*olal Project Square Footage-in:n he substituted for"Total ilroject Cost-
I _ i
CITY OF S.ULEa1
PUBLIC PROPERTY
DEPARTMENT
u�aai�ouaa�u
wvae i>o v+wMcrcw st•asr•!�K V�owsarrs Otf'e
nn.+�ar,ssssy•a..a r.s.i,o.sw
HOMEOWNER LICLNSB EXE.MMON
Plow Mat
DW
Job Location 5 �6 m ens'-)z 1 a I /t '�'a;< r.w Al r¢
Home Owner Address
Home Owner Telephone � 7k 74 t 9 4 r)
Preens Mailing Address
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings ot1 two Units or leas and to allow such homeowners to engags an individual for
hire who,does ant possess a licenses provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Person(s) who owns a pared of land on which hdshe redden or intends to reside,on
which then is, or is intended to be,a one or two family dwroWng, attached or detached
.structures accessory to such use and/or fum structures A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
-homeowner"sha11 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 understands the City of Salem
Building Department minimum inspection procedure d requirements and that hdshe
.vill comply with said procedures and requirem
HOMEOWNERS SIGNATL
APPROVAL OF 3UILD VG CISPECTOR "
See other side for state code
ii
CITY OF SALEN19 AksS.1cFiL'SET S
SULDNG 0EP.IAT1tLNT
120 W-UHNGTON STXM, Ye FLOOR
TM (978) 745.9595
K1313FRIEY DUXOLL FAX(978) 740.9843
MAYOR IHo.+w ST.PtFaits
DIRECTOR OP Pl 8L IC PQ0PEJtTY/8LM0 VG CO\pqu(ON EA
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 11 I.S
Debris, and the provisions of MOL c 40, S 54;
Building permit M is issued with the condition that the debris resulting from
1 11, S I30A.
11 work she)) be disposed of in a properly licensed waste disposal facility as defined by MGL c
The debris will be transported by:
(name of haular)
The debris will be disposed of in
(name of Gwdily)
Oddraia of Ft.,hty)
uynat4' ri,
licim
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