21 NICHOLS ST - BUILDING INSPECTION TI3 - i y _-i O o 6 r--
The Commonwealth of Massachusetts
Board of Building Regulations and Standards RECEI EQ CITY OF
UlfMassachusetts State Building Code, 780 CMR INSPECTION' SEA
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a P 24
One-or Two-Family Dwelling �t4 ,
-.This Section For Official Use OrtlY � p,..,.
Building Permit Number:' 9 , �� ° _' ,Date' pt d. �a- �t�� s� r
,4j#' ✓VAN �i
r
„ Building Official(Print Name)�y .ry , ';"`' ..s... .Signatuee °'?t k' '. w _ n. .a Da e
SECTION 1: SITE INFORMATION,.` tt`
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
a l N;cMIS �.
1.1 a Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
RI 0.0(.1 agms
Zoning District Proposed Use Lot Area(sq ft) Frontage(11)
1.5 Building Setbacks(ft)
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:
Zone: _ Outside Flood Zone?
Public lids Private❑ Check if yes2' Municipal 52r On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIPS ;"gyp.", A 'kK.+ .1 M,46,_. i
2.1 Owner'of Record:
Jfsse I Sw\iw MA o11-t0
Name(Print) - c` City,State,ZIP
aL ( iallol5 YirtlA S010A41t841 �Sskdeho?ewtno�-luwlx••cUw
No.and Street Telephone Email Address
SECTION 3-DESCRIPTION OF,PROPOSED WORK,(check all that apply) , ?' .tr'..,.;
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) d I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of ProposedWorkMGe rnrrr eksFiM. S�Jid� wr new D4 viu l
�� Ivu'.,� r�kv ,•4 nth ,r 1e.�16S
SECTION 4-.ESTIMATED CONSTRUCTION COSTS
Estimated Costs '
zu
Item 3Y� Ofncial Use Only ,a$ 'g4t T2 £-vi
Labor and Materials - t. . �.;� :.`
1 Budding Permit Fee:$ r t Indicate how fee is determined:
1. Building $ 3500
2. Electrical $ 60 00 ❑Standard'City/Town Application Fee Gm
p Total Project Costs(item 6)x multiplier � x mee
3.Plumbing $ NJ A 2 Other Fees $ re t,y:
3 e'6 t - Y a "•
4.Mechanical (HVAC) $ N A Ltst
5. Mechanical (Fire "
Supp ression $ N A Total All Fees
s
:Check No=> Check Amout Cash Amount
6. Total Project Cost: $ 35(e0.00 nr �'
q Paid in Full ❑Outstanding Balance Due:
5Ct )T TID � t O . (D t1
SECTION 5:"CONSTRUCTION SERVICES,,,
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
r TYPe ^ ,. ,d Descnpunn
No.and Street ��u t
U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/Town,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
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State,ZIP Telephone
t SECTION'6 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M G L 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 ORCONTRACTOR`APPLIES FOR BUILDING PERMIT
�� s.
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.
Print Owner's Name(Electronic Signature) Date
F 4 SECTION 7b: OWNERr OR'AUTHORIZED'AGENT DECtARATIONii
f
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.
3esfr. Der 6 4 r
Print Owner's or Authorized Agent's N e lectronic Signature) Date
„ NOTES:. -1, �t ?'. ': Ae r .gym
1. 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 can be found at
www.mass. oI v/oca Information on the Construction Supervisor License can be found at www.mass.eov/dns
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage,finished basementlattics,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
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
CITY OF SALEM, MASSAC IUSETTS
�fn fit BUILDING DEPARTMENT
120 WASHINGTON STREET,3m FLOOR
ysm TEL. (978) 745-9595
FAx(978) 740-9846
KIMBERLEY DRISCOLL
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date
�1�114
Job Location al nlWS S}rcc�
Home Owner Address StkW-t
Present Mailing Address SCkV .
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 that 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 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 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 INSPEC
City CF SIU-Emb A-1SSACHUSETI'S
DEP.1R'I1tG`iT
WASHLNGTON S-MEET, 3w FLOOR
TEL (973) 745-9595
KINMERE EY DIUSCOLL F."(978) 7-14)4 S
,bLAYO;2 r-toact3 sr.PtEug
DIRECTOR OF PUBLIC PROPERTY/HCLLOLNG CO3L\II55I0
NEZ
Construction Debris D
(required for all demolition and renovation
a work)
Vlt
In accordance with Debris, the sixth edition of the State Building Code, 730 CA(R section 111,5
and the provisions of IMGL c 40, S 54;
Building permit y
this work shall be disposed is issued with the condition that the debris resulting from l 11. S 1 SOA. of in a properly licensed waste disposal facility as defined by tMGL c
The debris will be transported by:
• y
(name or anuler)
The debris will be disposed of in
(rt•unt of tardily)
si X turcuf'permiLtpplicanr
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