134 NORTH ST - BUILDING INSPECTION (2) -115 ' 92 f Z5 C_V zREGEI
� �
'rhe Commonwealth of lMassachusett�SpECTIONAL SE YICE
Yv
Board of Building Regulations and StanddOF
a�rrdds CITY NIMassachusetts State Building Code, 780 CMR Lhir 1pb �EC IS P keJ��.1/ur20//
I Building Permit Application To Construct, Repair, Renovate r emolish a
l�J One-or Two-Family Dwelling
This Section For Official Use Only
vFZoningDistrict
Permit Number: Date Applied.
Official(Print Name). - Signature . . Date
SECTION 1:SITE'INFOR,NIATION
r��jj'Address: 1.2 Assessors M1tap& Parcel Numbers
ft� STi2vn,mFl Ol`�1s an acce ted street?yes no rio hlap Nwnber Parcel Numberng Information: 1.4 Property Dimensions:
trict Proposed Use Lot Area(sq 11) Frontage(It)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if ycsE3
SECTION2: PROPERTY OWNERSHIP!'
1 O vnert of Record: \Q
ca 1 O I q
w o k L-eNA
IPme(Print) City,State ZIP
12A v,A nm��8-6d23 Cent, - l7o�tY T@.k'uKo�
No.and Street Telephone Email A dresg
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work=:
SECTION a: ESTIMATED CONSTRUCTION COSTS
licit] Estimated Costs: Official Use Only
Labor and Materials -
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
�. Electrical S ❑Standard City/Town Application Fee
❑Total Project Costa(item 6)x multiplier x
3. Plumbing S !!s,QtherFees: S
4. Mechanical (tIVAC) S List:
5.,Mechanical (Fire S
Suppression) "total All Fees:S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S 3 2(0 ❑paid in Full ❑Outstanding Balance Due:
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Dale
Name of CSL Holder List CSL Type(see below)
Type - Description
No. and Street
U Unrestricted(Buildmits up to 35,000 cu. It.
R Restricted 1&2 Family Dwelling
C ityfrown,State,ZIP M Masonry
RC Rooting Covering
WS Window and Sidina
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address I U I Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
I IIC Company Name or HIC Registrant Name
No. and Street Email address
City/Town, State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INMURANCE AFFIDAVIT(M.G.L.c. 152.1 25.CM)',
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
I,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.
PA NOF LT i F C!'Pt `le-c�;r� 11 -Ac±11 -,
Print Owner's Natne(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.
PANi)1--- L1 I_G �A ceynbiec-t-S-Q04.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 I.G.L.c. 1 d2A.Other important information on the HIC Program can be found at
www mass cov'ocn Information on the Construction Supervisor License can be found at www.nmss.�,o+-'dps _
2. When substantial work is planned,provide the information below:
'rota) 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
'rype orcooling system Enclosed Open_
i. "Total Project Square Footage"may be substituted for"'roml Project Cost"
QTY OF SALEM, MASSAQ IUSETTS
gtj BUILDING DEPARTMENT
--- -- -- -- >>S Its'— --- - - ---- - --120W_ASHINGTONSTREET,39DFLOOR
�\nvxon+ TEL. (978) 745-9595 — — — ---- ---FAX(978) 740-9846
KIMBERLEY DRISCOLL
MAYOR TY-IOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DateT)_;,C(2YynLi ( — )5^:)Olq \
Job Location 1.2')4 nlnT�� 51 "�G�eyn V A)A OLCLq tiD
Home Owner Address (�nayNP-,\N
Present Mailing Address 114 tnn-oV1 ST , ' C)akV✓1 , m)ll nio4c7
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 INSPECTOR
13U tio��h �Y , S Iew� VIA lDiq-4-0
I
�ric� �1�0� oak , �,dd��1���J-� �u�1��'0o v►�.
i
CA •
f
W 0 ui
f
t
f
SS1owe� ,
f
a
f
t
i
r i
;�
{ 1 ggVV J l
,,7f��%l ,Mt,,,yp.t �..Y t^,ci:.F.'�y;v I`, ! ;�,1.; s�1l�J=f� r4i� ��4i`.-'� .I�;
i � I 1 � �
" i
� �
.,;�l�r• i
[ s � � ¢ i.
j� � , � a '
.��--.r....; !� 1
i �.a,.;
�_ � j s i�:
0 �..�1�,� -� ( -r .
� � � � ���-
� � �
r �
� ,
a . . _ !
QTY OF SALEK MASSACHUSEM
BUILDING DEPARTMENT
120 WASIHNGTONSTREET,3ADFLOOR
TIEL. (978)745-9595
F
KIMBERLEY DRISOOLL FAX(978)740-9846
MAYOR THomA.S ST.FIERRE
DIRECTOR OF PUBLICPROPERTy/BUILDING GOMNIISSIOMR
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 111.5 Debris,
and the provisions of MGL c40, 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 deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
rric, � CU Posy
(name of hauler)
The debris will be disposed of in:
(name of facility)
1 c1� nSo•� T l A 0M2
(address of facility)
Signature of applicant
_Dece rn - L
Date