185 NORTH ST - BUILDING INSPECTION (3) k '
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CNIR SALEM
J Revised Slur 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Fmnily Dwelling
This Section For Official Use Only .
Building Permit Number: Date plied: I'
Building Official(Print Name). _ Signature- Date
SECTION 1:SITE INFORMIATION
LI Property Address: 1.2 Assessors Mlap&Parcel Numbers
I.l a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use [.at Area(sq II) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yams Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§5q) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check ifyes❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Owncrt of Record•
R-sme(Print) City,State,ZIP u
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition V Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work'• .-�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Nlaterials)
I. Building S _ I. Building Permit Fee:$ Indicate how fee is determined:
n ❑Standard City/Town Application Fee
2. Electrical $
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing .S 1. Other Fees: S
d. Nleclianical (11VAC) S List:
5. Slechanical (Fire S
Su cession) 'road All Fees:S
Check No._Check Amount: Cash Amount:_
6. Total Project Cost: ,S ❑ Paid in Full ❑Outstanding Balance Due:
Savo -M 5Lxy:1("?5C 7
SECTION 5: CONSTRUCTION SERVICES
5.1 Cmtstruction Supervisor License(CSL) e' _ O S ')- (S! 3
t U�c- Q License Number Expiration ate /a R
Name of CSL Holder List CSL"type(see below) I^ w V'� S1^✓r(J t
L, '3 n Vt
No. and Street -Type Description
7(�,, U Unrestricted(Buildings u to 35,000 cu. ft.)
`kj c— '� O I-Q r'ro�rvr y�/ (7 R Restricted 1&2 Family Dwelling
City/town,State,ZIP 'b1a NI I o sn
RC Roofing Covering
WS Window and Siding
>� Q (� SF Solid Fuel Burning Appliances
t I - 77' Cd vl l�.A r�•�'P ` J p,'c./',l I I Insulation
Telephone Email address D 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 role hone
SECTION 6:WORKERS'COM1IPENSATION 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'
I,as Owner of the subject property,hereby authorize
t9 t t y- half,ja311.4tratterfelative to work authorized by this building permit application.
//
Print Owner s Nm (flectromc Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,)hereby attest under the pains and penalties of perjury that all of the information
to I -utI is applicatio a and accurate to the best of my knowledge and understanding.
Print Owner's or Ate rized Agent's Name(Electronic Signature) Date
NOTES:
I. An Ox ner 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
prugram or guaranty fund under NLG.L.c. 142A.Other important information on the HIC Program can be found at
teww.mass. ov'ori Information on the Construction Supervisor License can be found at www.mass.aoV.!dM
2. When substantial work is planned,provide the information below:
'fatal floor area(sq. It.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. 11.) 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"'fatal Project Cost"
CITY S OF S Ul EM Lv�WSACHUSE-ITS
J
BUILMIGDEPARTNt&YT
120 MASHCYGTON STREET, 3'4 RoOR
TEL (978) 745-9595
KIMBERL.EY DRISCOLL FAx(978) 740-9844
ab{AY012 THOSLAS ST.PIERRH
DIRECTOR OF PUBLIC PROPERTY/BUILDD;(;CO%NISSIONER
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 1 l 1.5
Debris, vid the provisions of MGL c 40, S 54;
Building Permit t# 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
l 11, S 150A.
The debris will be transported by:
(name ofhaulcr)
fhe debris will be disposed of in
(name of racaity)
(address of tacilily)
i
sir tnr of permit applicant
ia,ri.au i.N,
CITY OF S,V-F.Nf
PUBLIC PROPERTY
DEPARRTJdENT
V.Q.Au"04OU"
verve
itL 9-6r1S.II" •Ys r'r.ri0�ay
HOMEOWNER LICL►NSL EXE.M"10►N
Plow lriat
Due
lob I acados l
Homeowner AddFae
HOWIS Owner Pree Magog
Teo current esempdos ot"Homeowasea"was extended to iaehrdt owmer-oeeup•ted
dweUlnip of"" Units or Ica and to allow nxb homeowners to
him who.don not PC~a Hems%provided that the owner acts Capp
P,I� dual foe
DEFiNMON OF HOMBOWMM
Peson(d who owns a pared WNW an which be/sbt reaidee ar Intends to revidey o0
which there I; or Is intended to bey a art or two &Wlr dwGIURS attached or detached
struettxw accessory to such use and/or roan sgvoturra A person who constructs more
thaw one home in a two year pelod 1W not be considered a homeowner. Such
"homeownd'shall submit to the Building OQlci4 an a form acceptable to the Building
Otlrci4 that he/she be responsible for all such want performed under the Building
PemiL
The undersigned "homeowner"aaatunea responsibility for compiianoe with the State
Building Coda and other applicable*lawh usd retuladons
Tt;e undenigted "homeowner"cerdtlet that ha/she understands the City of Salem
Buildint Oepartrnent minimum inrpeerioa Procedures and requirements and thu helshe
*'11 comply with said Proeedurcs and requirements
HO IEOWNERS S/G.NA MRB
kPPROVAL OF WILDING INSPECTOR
See other rtde tat r(its C0de