4 MOUNT VERNON ST - BUILDING INSPECTION (2)r
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The Commonwealth of Massachusetts 3:e 4 F
CITY OF
Board of Building Regulations and Standards Pf / Massachusetts State Building Code, 780 CMR mb DEC 22 ,Qis1d12,2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only '
Building Permit Number: Date Applied:
Building Official(Print Name). Signature Date
SECTION l SITE INFORMATION`
1.( Property AJdr`e�s: 1.2 Assessors Map&Parcel Numbers
1 N Nlnu("-F V PC(lb(1 � 0?5 US55 - f)
I.la Is this an accepted street9 yes no Map Number Parcel Number
1 1.3 'Loving Information: _�`I�_ � ��"�" I.d Property Dimensions:
Zoning District Proposed Proposed UhA Lot Area(sq ill Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Private❑ al f�J On site
Public Zone: _ Outside Flood Zone? Municipal disposal system ❑
fill Check if es❑
SECTION 2: PROPERTYOWNERSHIP't
2.l Ownerr of Record:
AnrlPrSor� True c �gClI 'JOY eel MR ovilo
INt1me(Print)Gatl whtME �(-US�C CityState,Zip
4Mnftci- Yer g1SL#q±zj3 0 Gciw3316LbI•Com
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKA(check all that apply)
New Construction❑ Existing Building IQ Owner-Occupied 8 Repairs(s) IS Alteration(s) ® I Addition Cl
Demolition ❑ Accessory Bldg.❑ 1 Number of Units I I Other ❑ Specify:
Brief Description of Proposed Work':
(y1C (lC 1 +
re
SECTION a:ESTIMATED CONSTRUCTION COSTS
Itcnt Estimated Costs: Official Use Only
Labor and Materials
1. Building $ I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ Oa ❑Total Project Cose(item 6)x multiplier x
J. Plumbing S QQ0,C6 2. Other Fees: $
d.Mechanical (HVAC) S List:
5.Althanical (Fire S total All Fees:S
Su ressimt)
Check No._Check Amount: Cash Amount:_
6.Total Project Cust: $ OW,CO ❑Paid in Full ❑Outstanding Balance Due:
(rlfatL TO Gam. l�llca).) 1
is���
r
SECTION 5: CONSTRUCTION SERVICES
5.1 •CunstructionoSuypervisor License(CSL)
License Number Expiration Date
Name of CSL Holder List CSL Type(see below)
Type Description
No.:md Street
U I Unrestricted(Buildings u -to 35,000 cu. it.
R Restricted 1&:2 F:unil Dwellin
Cityfrown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
f I Company Name or HIC Registrant Name
No.and Street Email address
City/Town, State ZIP Telephone
SECTION 6:WORKERS,COMPENSATION INSURANCE AFFIDAVIT(M.G.I c. ISL i 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 Isbuance of the building permit.
Signed Affidavit Attached? Yes ..........O No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE.COMPLETED WHEN'
OWNER'S AGENT OR CONTRAGTOIL APPLIES FOR BUILDING.PERMIT
1,as Owner of the subject property,hereby authorize
t9 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 application is true and accurate to the best of my knowledge and understanding.
Lo a �a as
int Owner's or Authonz %gcnt's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or as owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program),will nut have access to the arbitration
program or guaranty fund under NI.G.L.c. 1 a2A.Other important information on the HIC Program can be found at
�awvv mass cov'oea Information on the Construction Supervisor License can be found at www.mas�
2. When substantial work is planned,provide the information below:
'total floor area(sq. ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. ttJ Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of ha ltbaths
Type of heating system Number of decks/porches
rype of cooling systcai Enclosed Open
t. "rota, Project Square Footage"may be substituted roc,rotal Project Cost"
Ch YOFSALEA MASSWAMT
BMUmWDaraMn•
�'.svnwraerS7tawr,rA M
rna zrz L Aear 7�4le/6
adAYCR DMUSUMM
Dn mmm a'R rr/atn as
Construction Debris Disposo►/Afflddvit
(required foralf. demolition and renovation work)
In aocordenor with the shah edition of d►e Soft&di W Code, 7W t�Sedian 12LS
artd the prVWM OfAOIGL o10,554;
aon onthatthe debris rasa ��BPero*it isloadwothe
from till;workshe6 be disposed of in a prgperly licensed
waste depma facility as defined by MGL c ill,S 15dt
The debris will be transported by.
(name of hauler)
The debris will be disposed of in:
C�eo�cle�u�n �u m P
(name of fadlity)
01733
(address of facility)
4ignature o)f1ap1 /cant
l /X.,I rrY��(n
Date
Y.
CITY OF SALEM, MASSAQHUSEM
BUILDING DEPARTMENT
120 WASHINGTON STREET,31D FLOOR
TEL. (978)745-9595
F
KIMBERLEY DRISCOLL FAX(978)740-9846
MAYOR THOMAS STYIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE:-)) � 'Qa' al7Ily
1OBLOCATION q MOUnI VPC[)t-2D (pICij()
� I
HOMEOWNER ADDRESS: � ime- Q-:5 QC]OJG
PRESENT MAILING ADDRESS: SQt11e.. QS QkoVN
The current exemption of"Homeowners"was extended to include owner-occupied dwellings of two(2)units or less and to
allow such homeowners to engage an individual for hire that does not possess a license, provided that the owner acts as
supervisor.
Definition of Homeowner:
Person(s)who own a parcel of land on which he/she resides 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 the responsibility for compliance with the State Building Code and other applicable
by-laws and regulations.
The undersigned "homeowner"certifies that he/she understand the City of Salem Building Department minimum inspection
procedures and requirements and that he/she will comply with such procedures and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR