10 MOULTON AVE - BUILDING INSPECTION (3) ef
me Communwc:dth ol'Massachusctts CITY
IIl1U1 Board of Building Regulations and Standards OF SALEM
Massachusetts Slate Building Code, 730 CMR, 7"edition Rewsed Ainmrrr
I
Building Permit Applicatio Construct, Repair, Renovate Or Demolish a
Une-or Tt (o7unilp Duelling
This ection For OlFcial U Oni —
Building Permit Number: ate Applied:
Signature:
Building, o net/Inspector of Buildings Dale
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map At Parcel Numbers
/ h9o� Parcel Number
L l a Is this an accepted street'?ycs no.
Map Number
1.3 Zoning information: 1.4 Property Dimensions:
Zoning District Proposed Use Lut Area(sq 11) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L e.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal Q On site disposal system ❑
Public m Private❑ Check if XcsC1
SECTION 2: PROPERTY OWNERSHIP*
2.1 Owner'ofRecord: /O h7oo/ '42v`
Name(Pr Address for Service:
Sign�tarc Telephone
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 Pro�osed Wo k1:
o `
�ir GC ti S ir• .'u i., h � iC
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials
I. Building S / OOU•coo I• Building Permit Fee: S Indicate now fee is determined:
❑Standard City/Town Application Fee
2. Electrical S / 46 oo.vo ❑Total Project Cost'(Item 6)s multiplier s
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S Total All Fees: S
Su ression
Check No. Check Amount: Cash Amount:_
6. Total Project Cost: S GO O,cro ❑Paid in Full 0 Outstanding Balance Due:
=AddrCM
CTION 5: CONSTRUCTION SERVICES
or(CSL)
License Number Expiration Dale
I.ist C'SL 1)pe Uee below)
rs pe I Descri Lion
I I I!nreslricteJ(up 10 35.000 Cu. Ft.)
Signature
R I Restricted 1&2 Family Dwelling
Al I Masonry Only
RC Residential Rooting C'overin
Felephone . WS Residemial Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
1) 1 Residential Demolition
5.2 Registered Hame Improvement Contractor(HIC)
I IIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
SignatureTelephone
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 .......... O No...........O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S ACENT 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.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1, 41111 14 ir-r Ui 5se as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of wner or Authorized Agent Date
(Signed under the pains and penalties of r'u
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 W have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 730 CMR Regulations I IO.R6 and I IO.RS, respectively.
2. When substantial work is planned,provide the information below:
Total floors 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 ol'balhrooms Number of half baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may he substituted lift"Total Project Cost"
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CITY OF S.XLX.Nf
PUBLIC PROPERTY
DEPARTMENT
w.aa 170 vAww.Gow 9nWW•su,.�wGADasms olf-e
tsrL ran+sssss�v..a+-ar+osaw
HOMEOWNER LICLNSE EXE.MMON
Phnse"t
Date d ryi,gr.G
Job Location l
Home Owner Address /o dl 4"/Ae,.. 4
Home Owner?elephone
Present Mailing Address (.0 ;.W'7 / '
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 who,does not possess a license,provided that the owner acts as supervisor.
DEFiNMON OF HOMHOWNEA
Persons)who owns a parcel of land on which he/she resides or intends to reside,on
which there is. or is intended to ben a one or two family dwelling, attached or detached
structures wcessory 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 OQicial.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 procedures and requirements and that he/she
will comply with said procedures and requir n
HOMEOWNERS SIGNAMME
APPROVAL OF BUILDING INSPECTOR
Sce other side for state code
CITY OF S.UF..NI, JtiL-kSS.A cHUSETI'S
BI:ILDLNG DEPARTJtENT
120 W.A.iHLNGTON STREET, 3' FLOOR
` TEL (978) 745-9595
FAX(978) 740-9846
KlJ®ERIEY DRISCOLL
.MAYOR TH0..%W ST.PtERRB
DiREGTOR OF FLBLic PROPERTY/BCILDLNG CONWISSIONER
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 111.5
- - ---Debris, and-the provisions-of MGL-c 40,-S54;--- - --------- --- -- ---- - -
Building Permit Al is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature ofpermit applicant
date
IcAnvlr Jew