14 NICHOLS ST - BUILDING INSPECTION The Commonwealth of Massachuscits Town of
` Board of Budding Regulations and Standards loomerw
Massachusetts State Building Code. 780 CNIR. T"edition Building Dept
Building Permit Application To Construct. Repair. Renovate Or Demolish a iddsoona
One. or A,o-FA#W Quelling
This Sectiori Fdr Official Use Only
Building Permit Nu c 1Date 4 plied:
1 Signature: /Q
Budding Commissioner/Ins for of Budding 1 Date
SECTION I sil'IrE[lill FORMATION
1.1 Property Address: 'J 1.2 Assessors Map 6 Parcel Numbers
1.IS Is this an accepted street''yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use La Arco(sq A) Frontage(II)
1.6 Building Setbseka(R)
Front Yard Side Yards Rear Yard
Required Provided I Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40.154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Public O Private O Check if sO P Y
SECTION 2: PROPERTY OWNERSHIP'
.J&w ers of Record:7!2��v2,- /S�j e ct
(JGiJr�s A Chet ST
Name(Pant) Address f ice:
Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORKS(cheek all that Apply)
New Construction O Existing Building O Owner-Occupied O Repairs(s) O Alteration(s) O Addition O
Demolition O Accessory Bldg. O 1 Number of Units_ I Other O Specify:
Brief scription of Proposed Work':
rPmd//P Or7_4; Shine/2. /ay,-e,e On /XP rdo Gr.7c✓
R v.0 V tin n
SECTION 4: ESTIMATED CONSTRUCTION COSTS
It Estimated Costs: Official Use Only
Labor and Materials
1. Budding 1. Building Permit Fee: f Indicate how fee is determined:
O Standard Ciry/Town Application Fee
2 Electrical f O Total Project Costs Item 6)x multiplier x
Plumbing f 2.. Other Fees: f j, p p O -
i. %icchamcal (HVAC) f List:
s Mechanical (Fire S Total All Fees. f
Su ression
Check No. _Check Amount: Cash Amount:_
' A Total Project Cost: f ❑Paid in Full ❑Outstanding Balance Due
�� { /v // � h' e
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Super%isor(CSL)
'' . License Number Expiration Date
N,tror of CSL-J1¢der List CSL Type IKe below)
EDRes,5dkittial
Description
A,kkess
tncted u to J3,000 Cu. Ft.
cied IA2 Fared Dwdhn
S iymwre Mason—
RCOnl
Reside— Roofin Covenn
Telephone nual Window and Stdm
nual Solid Fuel Btunm A liance Installation
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.e. 152.J 2SC(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 7s: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
L 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.
Si nsttue of Owner Date
SECTIONN77b:OWNER'OR AUTHORIZED AGENT DECLARATION
Q ✓ //��'/!/Q S h� ,as Owner or Authorized Agent hereby declare
tt,nt
at the s cements and information on the fci egoing application are true and accurate,to the best of my knowledge and
eha .
Signature of Owner or Authorized Agent Due
Signed under the gains and penalties of perjury)
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 Id have access to the arbitration
program or guaranty fund under M.G.L. c. 1 J2A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and I WAS, respectively.
2. When substantial work is planned,provide the information below:
Total Moors area(Sq. Ft.) (including garage, finished basement/anics,decks or porch)
Gross living area ISq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half.baths
Tvpe of heating system Number of decks/porches
T.peofcoohngcystem Enclosed Open
1 "Tool Protect Square Footage" may he substituted for 'Total project Cost"
CITY OF SALEM
.y PUBLIC PROPRERTY
`Y'„W% DEPARTMENT
9t 1_'Q v,••�It II\G';'ilV 51'H LET •SA P\1, It it II :I'1%�
Tr1:v78J43-9;95 ♦ I ss:978.740-9X46
Construction Debris Disposal Affidavit
( I
rat aired (ur all dot tolition 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, S 54;
Building Permit it - - 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 byn
"tname of hauler)
The debris will be disposed of in :.
/VH
(nume ut faci ity)
-
taddress of facility)
i
signature of immit applicant
,late
gohii ali Loc
CITY OF SALEN1
PUBLIC PROPERTY
DEPARTMENT
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HOMEOWNER LICENSE EXEMPTION
Pleaw Ftist
Day
Job Locados /�//Ui o�id/r ST
Home Owner Address /U Air 04v/1 S
Home Owner Telephone 97P- >u i— P 7 o
Present Mailing Addtew L/ sA m as' a6ou e.
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or leas 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 HOMEOWNER
Persons) who owns 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/oc.farm structures. A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeowners"shall submit to the Building Otflcial,on a form acceptable to the Building
Otflcial, 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 requirements.
HOMEOWNERS SIGNATURErGit� - T�e�t�✓L
APPROVAL OF BUILDING INSPECTOR `
See other side for state code