15 MOUNT VERNON ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board
i Bd of Building RegulationS and Standards P()K
' V r I Ml�Nll'll'.\I.fll
y. y Massachusetts State Building Code. 730 CMR, 7"' edition I SF
p l•p
Building Permit App Construct. Repair, Reno a[e Or Drnu)lislt a Krrisr/./ uw u,
One- or ❑w-Fainifr Bill e•llin,l
This ection For Official Use Only
Building Permit Nu Date Applied:
signawre:
Buil ng Comm..' pector of Buildings Dale
—_y
SECTION I: SITE INFORMATION
1.1 Propp'�erh Address: 1.2 Assessors Nlap & Parcel Numbers
x i s' 116:—Jk9.No, .) S — SAt AA --_
I.la Is this an accepted street?yes__— no Map Number ParCCI Numher
1.3 Zoning Information: 1.4 Property Dimensions:
Zorca,� District Proposed Use Lot Area tsq to Frontage(li)
1.5 Building Setbscks (ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Plo,Jcd
1.6 Water Supply: (M.G.L c. 40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone:' Municipal ❑ On site die wsul .c sic m ClPublic ❑ Private❑ Check it yes❑ P
SECTION 2: PROPERTY OWNERSHIP'
X2 1 Owner'oa�f{Jr2ecord:
�Jr�sse(.�P IS � �€kvonl ST"
-P int) Address for Service:
Sign i� Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ 1 Existing Building❑ Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Additinn ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
AGC CF- /
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
_ (Labor and Materials)
I. Building S 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
3. Electrical $ _ ❑Total Project Cost' (Item 6) x multiplier x
i
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ Total All Fees: S '
Suppression)
Check No. Check Amount i Cash Amount:_-_
Xb. Total Project Cost: $ S >(Paid to Full 0 Outstanding Balance Due:__.___
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Numher Expiration Date t .
Nance of CSL- Holder
List CSI_Tcpe Uce hclow)
T c Desciittion
\ddress
C Onrestnctcd (up to 35,IN00 Cu. FL)
R Restricted IRc1 Famih Duelling
Signature ,bl Masonry Orily
RC Residential Rooline Coxerufe
Telephone N'S Residential Wmdom:u:d Siding
SF RCSidenti:d Surd Fuel 8urmnc :\ t th:mcC In.I.Jldln-u
D Re>IdCnllal DCinohtinll
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Nance or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6: WORKERS' COMPENSAT ON INSURANCE AFFIDAVIT (lvi.G.L.c. i52. $'=506))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to pntvide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No ........... O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I
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
r-- _.
1 _ , 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 Owner or Authorized Agent Date
(Signed under the pains and penalties cf perium)
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(nut 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 730 CMR Regulations I IO.R6 and I IO.RS. respectively.
'. 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 tSq. 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
3. "Total Project Square Footage' may be substituted for "Total Project Cost"
J
�J
�. CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KIfOFllar eV.4•n
VAraa .- IMWASONG OMSTfiaT•3ALKHAMA0ftl M01970
'-' 7tL T L70-9S"# FAL 97L74&9W
HOMEOWNER LICENSE EXE.MFnON
Plea" Mat
Date-.. 3 ��log-
Job L wation (S NFT UGP,� J 2L
Home Owner Address Is W Vie.--J ST
HomeOwnerTelephona • ! i'40-7Kt—,RSO*
Present Mailing Address rS Mr VEeA;t>,j Salt�v1
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 HOMEOWNER
Person(s) 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 regulatioru ;
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 requirements.
HOMEOWNERS SIGNATL XE_
APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SALEM
PUBLIC PROPRERTY
�,, ,• DEPARTMENT
1 •.d..�".
I I I V'S '{i. 1—); \V 'i'S '4; 'JS 4,.
Construction Debris Disposal Allidavit
(rcyuired li)r all demolition and renovation wurk)
In accordance \with the sixth edition of the Star Building Code, 780 C NIR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit t is issued with the condition that the debris resulting from
this work shall he disposed of in a pruperly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
T�
(name of hauler)
The debris will be disposed of in :
(name of IacJity)
l uddres.ur qc ilirv)
'goal ee of permit applicant
date