10 MESSERVY ST - BUILDING INSPECTION Ay
'S, _ - --- I'he C'onunumceahh of Muss;n•huscfls _ _
l� Board of Building Regulations and Standards CITY OF
Massachusetts State Building Cude. 7SO CNIR �.\Ll:\I
fire i,ed i(„r vui
Building Permit Application To Construct. Repair. Renovate or Demolish a
()Pro-or TuvFunrill• Un•ellia,ar
This Section For Official Use Only
Building Permit Number
�I �+ _ Date Applic : _
Building 011icial(Print Nwn`) Si natureMPdrctl
I Z
WI ale
SECTION I: SITE INFORA1
I Property,address: 1.2 Assessors N
I.la Is this an acce ted street? ves no Map NumlKr Purcel Number
ZonIng Information: 1.4 Property Dimensions:
Coning District 11ropmed U,, Loa Area(sy It) Frontage III)
1.5 BuildingSetbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Witter Supply:(M.G.L c. 40.§54fl.)7 Flood Zone Information: 1.8 Sewage Disposal System:
Public O Private❑ _ Outside Flood Zone? Muniei d O On site disposals)s stun O
Checkif �cs❑ D po )�
SECTION2: PROPERTYOWNERSHIPa
2 Ownerl of Record..
UIVICan �jp0.fCtC(0 SCA
N;une(Pnm) City.State,ZIP
to Messe-Ryy ST. 1996-S?Y 57a5 V,6p (-aeio!EJ Ctkcy. 'o"N
Nu.:uaJ Street Telephone hmail Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ I E.xisting Building❑ I Owner•Occupicd ❑ Repairs(s) ❑ 1 Allerallon(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Spccify:
Brief Description of Proposed Work!:
17G2 aermdf 1:2t2 _ Gll-i P -tt-irl i t arninQ S V
o�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
llem Estimated Costs:
I labor and.Materials) Official Use Only
I. Building S I. Building Permit Fee: f Indicate how fee is determined:
2. Flectrical S ❑Standard City,To%vn Application Fee
i. Plumbing ❑Total Project C'ost'(Item m 6)x uD
lti leer
S ) _ x
. Usher Fees: S
4. .\Icclianic.d i11\.1('1 S List:
5 Mcdianird iFirr _------.-- --- .-- --
suppressiona S fot;ll .\IlPecs: S_
Check , 'heck Annnnll: \l'.uh mount:
Tulall'rnjectCmh. i Nu
� b ----( _.-.._..
O Paid in Full ❑Outstanding Balautce Duc:
„ r�
SECTIONS:
5.1 Construction Supen isor License(CSIJ
celise Numhcr \111rah0l Dote
PA: Uescriptiun
No and Street ji I hlrvstrielcJ t Ilia n ti it)35,1100 01. 11.)
R Re,trivied l&2 F.unil Dwcllini
N1 Mason e
RC iti,olin
u
Co
%vrin
%S W'jldow'0"Sid in
SF Solid Fuel 11imIng
g A pplianccs
hiulution
I dytlLng Hail address U Demolition
5.2 Registered Home Improvement Contractor(HIQ IIIC Regisir "nNuoilber lisp
indi'l Wg
111CCollipan) N.iiiivt)rlllC Registrant Niiiig
No. Luid Street Email address
City/Town,State,ZIP relephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 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 Affidavit Attached? Yes ..........a No...........13
SECTION 7a: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.
Ilrint UNsmer's Nanic(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 or my knowledge and understanding.
Date
Print owicri tit %tithon/vtJ Agoll 4 Nallig 111mitilim'lull, I I
NOTES:
I An 70\�iier\Ou obtains a building permit to do his her own work,or an owner who hires an unregistered contractor
(not registered in the Hume ImprovicnientContracturil-110 Program).will aa) have access to the arbitration
program or guanuity fund uiid%:r.\I,G.L. c. 142.A. Other important information on the HIC program can be found at
,\program
'," .,
I Information on the Construction Supervisor License can be found at w-),; '111,
2 2 \it 11 5 111131
. Wiens substantial al iwrk is planned, provide the information below:
rotal flour area(sci. ft garage, flnishcd basement attics,decks or porch)
Cross li\iog area i sq. it.) Habitable room count
I \taiii,cr offirvIflaces Number ol bedrooms
Num her of hallirounis \umbvr ofliall halls
I\pe of heating ;)stein Number 01'&Lks, pordies
l*\(lc ol'Cok,1i11q %swill
I oi,il Prow cquare Fool-liN"111,1N lie 'Uhslit"Icd Itir-l'oiA l)rt,j%:d Cost-
r
CITY OF SM.EI I
PUBLIC PROPERTY
DEPARTILENT
ku,outar^••••
wrae i�o vso•w,�o,,sraat•su+aa wa�oR�r,s Or•-e
HOMEOWNER LICENSE EXEMMON
Pfeaw Frist
Date I 1
Job Loeados AA esSe r LN Sf
Home Owner Address 1 U AA e s a r-y N
Home Owner Telephone R P7 B —59 4 - 5
Present Mailing Address /ri L4 e55 e r�� S a le n i e.l
The current eumpdou of"Homeowners"was extended to include owner-occupied
dwellings of two Units at less and to allow such homeowners to engage an individual for
hire who does not possess a liceam provided that the owner acte as supervisor.
DERNMON OF HOMEOWNER
Pe sons) who owns a penal of land on which he/she re ddes or intends to resider on
which theirs is, or is intended to bsr a one or two family dweWng, attached or detached
Muctura seceswry 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 compliance with the state
Building Code and other applicable by-laws and regdadons.
The undersigned "homeowner certifies that helshe understands the City of Salem
Building Department minimum inspection procedures and requirements and that helshe
Will comply with raid procedures and requirements.
HOMEOWNERS SIGNATI.
APPROVAL OF SUILDNG INSPECTOR
See other side for slue code