5 MOUNT VERNON ST - BUILDING INSPECTION ye The Commonwealth of Massachusetts
��- Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7"edition OF SALEM
Revised January
Building Permit Application 'ro Construct, Repair, Renovate Or Demolish a 1, =008
One-or Two-Family Dwelling
Thi ction For Official Use Only
Building Permit Nu er: Date Appli /
Signature: '�'�� �1��5� } 2
Building Commissio r/ nspecl dings Date Tl
CTION I: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
I.1a Is this an accepted street?yeses no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq fl) Frontage Ill)
1.5 Building Setbacks(it)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION2: PROPERTY OWNERSHIP'
2.1 rnerl of Record:
ClOn v _"Dfi MU2PF!'( ' A Ve r-non ST
Na a(Print) Address for Service:
Signature telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building Owner-Occupied 111.4Repairs(s) Alteralion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ er of Units I Other ❑ Specify:
Brief Description of Proposed Work' .5 I'31 Lf ✓o
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Labor and Materials) Official Use Only
I. Building S I. Building Permit Fee: $ Indicate how fee is determined:
�. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S -75'00. p p 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES i
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL-I[older List CSL I's pe(see below)
ry pe Description
Address li Unrestricted(up to 35,000 Cu. FL)
R Restricted 1&2 FamiIX Dwellin
Signature M Masonry Onl
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 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 .......... ❑ No...........❑
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.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
Owner or Authorized Agent hereby declare
that the statements and: non a foregoing application are true and accurate, to the best of my knowledge and
beh
L /n/DfJ M tr
Pr'.t Name , - ^
Signature of Owner or Authorized A Cent Date
(Signed under the pains and ocnalties of er 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 not 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 780 CMR Regulations 110.116 and 110.115, 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 halt baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF S.UYENf
PUBLIC PROPERTY
DEPARTMENT
KJIOWSY O�.ryw
NdAvm IbWAYOMGWWSMK T•SMAK%UM 011SEM01970
nL 9-VUS-9s99•FAL 976•74&9W
HOMEOWNER LICENSE EXEMPTION
Pia" Prot
Dale i, _ ,-2 - d �/
Job Locatim 6- r v t R NO N S t
Home Owner Address 5 r-,T ve-.en)z�>n) .S')
Home Owner Telephone 9�s - -7 v L/ —7 i 9 e,
Presses Mailing Address.
The current exemption of"HomeownerC was extended to include owner-occupied [/
dwellings of two Units or 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.
DE INMON OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or interds 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 structurea. A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
" rneownce sh" submit to the Building Otticial, 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 understand$ the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE
,APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF S.U.E.%l, .L-kSSACHUSETTS
Butmmr.DEPARTMENT
120 WASHLSIGTON STREET, P FCOOR
TEL (978) 745-9595
FAx(978) 740-9846
KISBERLF-Y DRMOLL
MAYOR THOMAS ST.PtERR8
DIRECTOR OF PUBLIC PROPERTY/BUMDLNG COMMISSIONER
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 t t 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# 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:
i`�e
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit a plicag
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slate J
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