14 MOULTON AVE - BUILDING INSPECTION (3) The Commonwealth of Massachusetts
►k Board of Building Regulations and Standards
\ � MEMO
Massachusetts State Building Code, 780 CMR, 7'"editionlh #*Wloso&A&
Dept
Building Permit Application To Construct, Repair. Renovate Or DemoliOne- or Tito-Family Duelling
xU This Section For Official Use Only
Building Permit Nu ber: Date Applied: �J
Signature: `'� -)/ b/09
Bolding Commissioner/Inspector of Buildings Date
SECTION I: SITE INFORMATION
1 ,P. qp Ftyv u�e�•N t f A.vO� v� 1.2 Assessors Map& Parcel Numbers
1.la is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq n) Frontage(it)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
F2N
Provided Required Provided Required Provided
y:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
ate❑ Check if es❑ Municipal ❑ On site disposal system ❑
SECTION PROPERT'Y/OWNERSHIP' t%Grd: C) ICJ i'`i Mau��f`-j t+'ye
/1 Address for Service:
QN--
Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction Q1 Existing Building� Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition tiY
Demolition ❑ I Accessory Bldg. ❑ Number of Units_ Other O'Speciy: fV CC—C
Brief Description of Proposed Work': I L 1.0 to
U eti
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) $ List:
5. .Mechanical (Fire S
u ression Total All fees: S
Check No. _Check Amount: Cash Amount:
6. Total Project Cost: E ��� ❑ Paid in Full O Outstanding Balance Due:
T
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
Lireroc Numtnr Expiration Date
N.4me of CSL Hpldcr List CSL Type(we below)
s
T Description
Address
U Umest"'crtdup to 35,000 Cu. Ft.)
R Revncted lag Family Dwelling
Signature M %Iasonry Only
RC Rcsvdenuol Rooting Covering
Telephone VS
Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
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 .......... 0 No........... O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 1150 as Owner of the subject property he
7an,
ize to act on my behalf,in all matters
to or ut on d by t ilding permit application.
of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I , as Owner or Authorized Agent hereby declare
t statements and information on the foregoing application are true and accurate, to the best of my knowledge and
b
Pme
Se of Owner or Authorized Agent Date
Sunder the ains and enalties of r uNOTES:
IOwner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
t registered in the Home Improvement Contractor(HIC)Program),will no have access to the arbitration
ram or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
struction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.R5, 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 of bathrooms Number of half/baths
Type of heating.system Number of decks/porches
Type of cooling system Enclosed Open
J. "Total Project Square Footage"may he substituted for 'Total Project Cost"
e -
CITY OF &XI EM
PUBLIC PROPERTY
DEPARItiiENT
Kl1OF1liY f]�wYY l
NAY@ 13 WAMWAG� STUM 9 SA1LM HAMACHLSff 17019-0
T L VL745-9S"*FAx 9711-740994
HOMEOWNER LICENSE E7KLM"I0N
Flew Ftrtnt
Date
Job Location , , 11+Y�
Home Owner Address L- q
Home Owner Telephone /5 5
Present Mailing Addrea J ,J
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.
DEFINITION OF HOMMOWNMt
Persons) who owns a parcel of land on which he/she reside@ 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 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 procedur d uirements and that he/she
will comply with said procedures an eg '
HOMEOWNERS SIGNATL /
APPROVAL OF BUILDING INSPECTOR
See other side for state code
' CITY OF SALEM
sr•r �", PUBLIC. PROPRERTY
DEPAIZ"I"MENT
tl , , I:: q ,. lr. . , .>..;Ilr � vlll vl. \I\..� • .I' .
I11 v'9.•J:. I:.i: � I Iv ':'8 '�. ' i L
Construction Debris Disposal Aftida-t it
(tv LI uircd lbr all demolition and Icnuvation wurk)
In accurdance ith the sixth edition of the State Building Code, 780 CTIR section I 1 1.5
Dchris, and the provisions of NIGL c 40, S 54;
Building Permit to is issued with the condition that the debris resulting from
this work shall he disposed of in it pruperly licensed waste disposal Iucility as defined by MGL c
III. S 150A.
The debris will be transported by;
111JR11C ul Ilaulrr)
I he debris will be disposed of in
Q L_ �s(61- SSA_
I uJlnr ul Iaaht.v)
IJJJrrv. ur 1]cv Glv)
L'IIJWIC illllll .1llhlll Jl It
JI:
I