3 MESSERVY CT - BUILDING INSPECTION e.
7 --- I'lie C'ontltte11\1'callh of blassachuselts
a Board of Building Regulations and Standards CITY OF
Massachusclts State Building Cude,•790 CNIR SALE\1
DA Building Permit Application 'Po Construct, R¢pair, Renovate Or Dcntolish u
One- or rivo4la till Du elliu.\+
This Section For OlTtcial Use Only
Building Permit Number: Date Applie ; oei
'y L_Ifel 4 -yTYLZ, -
lluilding Official(Print N:une) Kpalurc ale
SECTION I:SITE INFORAIA ON
F.5 -
Front er t Address: r
p Y 1.2 Assessors Alap di Parcel Number
�f17�-his an acre ted street?ree(? a binp Numhcr I'urcel Number
ing Information: 1.4 Property Dimensions:
istrict Imposed(1ve Lot Area lay IO Frontage IfOding Setbacks(R)
Yard Side Yunls Rear Yard
Required Provided Reyuircd Provided Required I'roviJed
1.6 Water Supply:(M.O.t.c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public O Privala O Zone: _ Outside Flood"Luna? Municipal O On Bile disposal s).vtem 0
Checkir cs0
SECTION 2: PROPERTY O RSHIP'
wner'of Record
N;wta(Pri 0 City-Slala,I.IP
No.and Slrcet clephone Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ I Repairs(s) C3 Alteration(s) ❑ I Addition ❑
Oenwlition O Accessory Bldg.l] Nul f Units_ I Other O .Spcuq:
Brief Description of Proposed Work :
SECTION 4: ESTIMATED CONSTRUCTION COSTS
flan Estimated Costs: Official Use Only
(Labor and Materials)
I. Building S 1. Building Permit Fee: S Indicate how fee is determined:
'. Flearical S O Standard City+Tawn Application Fee
❑Total Project Cost'(Item 6)x multiplier
t. I'lunhinq S ,. Other Fees: S_ -
J. Medianie.d ill\ \('t 5 List:__
j \Icchanicdl Wire S
�a +rc>smn: royal .\II Fees: S
Che.A Vo. ('heck :\nnnurt: ('.1ah \iwnuu:
1, 1'utul Project Cast i' SOS 0 P.tid in Full 12 Owsl:wding Ilahmce Ouc:
SEC HON S: CON.iI'RIIC'TION SERVICES
i.l Cunstructimt Supers isor license lC'SLI
I icenec Numhvr - -- .... I �piratiou Date
N.une ul'C.\I. I Inldef I i,l oI. I)pe hcc belum,l._
_ , _. h)Pe Description
llrcet
lI 1inrestnct"II)uiWin sli tojs,11Utlnl. It.l
R licitrivwd 1l2 F.unil Dnellin
Cit)/fours.Slac,/II' ----- .\I \lason .
RC' Roolin Onerin
K'S H'induw.tad Sidin
.SF Solid Fuel Burning Appliances
I Imululiun
1'elc hone Ffnail addrvxs D Denudilian
5.2 Registered Home Improvement Contractor(HIC)
INC Rcgistratiun Numhvr I\111ruliuo Date
I IIC C'ompan) Name or I IIC Itegi.struni Nunes j
No.and Street hlnail address
City/Town, State ZIP felt hone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152. 1 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 AMdavit Attached? Yes .......... I] No...........0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
C v
1733 O ner of the subject property,hereby authorize
to on my behalf,in all matters relative to work aulhbrized by this building permit application.
I'riu{U wrie(ElectrDlgnatuR) _7 q,- ao TTtd
mtc S
SECTION M 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.
I'rim Uiiner s 'r:\udntri/,. ,\pent's N;une Illlectronie Signawre) DuW
NOTES:
I. An Owner who obtains a building permit to do his,her own work,or an owner who hires an unregistered contractor
Inot registered in the Hume Intprovenienl Contractor(HIC) Programl,will rrrr have access to the arbitration
Program or guarmly fund under M.G.L.c. 142A. Other important information on the HIC Program can be limnd at
I Information on the Construction Supervisor License can be found at ii ii.i In.l•; �t'i 'll"
\\'hen substantial work is planned,provide the information below:
Total flour area(sq. R.) _ ____,._t including garage, finished basement allies. decks or porch)
lirois liv ing area lsy. IL) ______ ftabilable roues count ._ _. ... ._ .
t \unthcraf fireplaces Number of bedrooms
\umherot'bathrooms .. .. --- \untbcrof'halfhaths .. .. . .
I\pc al It¢oling i)itcol _ . . \umhcr of decks, ponhcs
I')p �c t'coolittg iN item Ihtcloied ..t)I'en
i. "I\na1 11wivo Square Foot.Igc,nun he iuhititmcd l'or foal I'rojeat C'oit'•
i
4
CITY OF S.u.Ear, Akss.1cHUSETTS
dLLLOLVC CEP.IA-nLLSr
I .0 %V..U.404GTON SrlgXr, J"FtOOg
rEL k978) 745-9591
KIJ®ERr YOUXOLL F.kx(973) 1W.9m
MAMA moxcu ST.PMAXA
DIRBCTOIt OP PI:HLlC PROPIATY/BCmmmG CO.%Oj1SSIO,VEIt
Construction Debris DISPOS31 Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 190 C�biR section I I
Debris, and the provisions of MGL o 40, S 54; t.J
Building Permit Al is issued with the condition that the debris resulting from
this work shall be disposed of in a pro
—
I If. S I JOA. perly licensed waste disposal facility as defined by&IGL c
The debris will be transported by: /
(n+me of hauler)
The debris will be disposed of in
l�ddna oY(�cih�Y)
�! +R+ro uf;,e�m ! ipphcint v
CITY OF S.UI F.NI
PUBLIC PROPERTY
DEPARTMENT
u.u.a�s�o.snxs
w`'d i 3o a..a ommon sneer•aKara MAUACM ims 0rf-0
ru.9-L745.95"•ItAx l-67+67aN
HOMEOWNER LICLNSE EXEM"104N
rfew "I
Date
Job Location
Home Owner Address
HomeOwoarTelepboae � 79 —2 LS—lorse�
Preesoi Mailing Address
The current exemption of"Homeowners"was astta dedd to include owner-occupied
dwellings of two Units at lea and to allow such homeowners to engage an individual for
hire who.does not possess a license provided that the owner acts as supervisor:
DFXIN TON OF HOMEOWNER
Parson(s) who owns a pared of land on which hdshe resides or Intends to reside on
which there is, or is intended to be a one or two family dwelfln& anwhed 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 Oi fci4 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 bylaws and regulations.
The undersigned "homeowner'certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATLRE
APPROVAL OF BUILDING IrSPECTOR
See other side for state code