195 NORTH ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts CITY
Board of Building Regulations and Standards
� OF SALEM
Massachusetts 1 S Building Code, 780 CMR, 7m edition Revised Junuury
Building Permit Application To Construct, Repair, Renovate Or Demolish a l• '008
One-or Two-Family Dwelling
This Section For Official Use Only
�'vw\ Building Permit Number Date Applied:
v\ Signature: wz'�jz)
\\\ Building Commissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Prooverty,Address: 1.2 Assessors Map& Parcel Numbers
I2
I.la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq B) Frontage(tl)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Wat r Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O/On site disposal system ❑
Public Private❑ Check if es❑ p D� y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ot r'of Record•
O(n5
Name rint Address for Service:
� l
Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check that apply)
New Construction❑ Existing Building❑ 1 Owner-Occupied Repairs(s) Cr Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Bri f DesSription of Proposed Work': n./ oo�— �✓ r
T SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building 5 'D 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard Cityrrown Application Fee
2. Electrical S
❑Total Project Cost 3(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S Total All Fees: S
Su tiression
Check No. Check Amount: Cash Amount:
6.Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of C'SL• I lolder
List CSL 1ype(see below)
Address T5 pe I Description
U I Unrestricted up to 35,000 Cu.Ft.
R Restricted IR2 FamilyDwelling
Signature M I Masonry Only
RC Residential RoutingCovering
rclephone WS Residential Window and Siding
SF Residential Solid Fuel B=init Appliance Installation
U I Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
IIIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone ,
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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...........0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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
I, A1.,✓ ,�� ,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.
Prfm
Si reder the =ins and r Authorized Agent Date
Si nalties of 'u
NOTES:
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 aoj have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 I0.116 and 110.RS,respectively.
2. 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(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"may be substituted for"Total Project Cost"
P'
CITY OF S.0 E.Nf
PUBLIC PROPERTY
DEPARTMENT
Klf�r� N p�w.vw
Mwvoa �r/AYUNL.�aI SnEaT•SALAK MwaACW S9M Ot 9'e
T11 97L71i9S99• F.VL 978.7469W
HOMEOWNER LICENSE EXEMPTION.
Ples" flint
Dar.
Job Location b,< ,n a4 Kd- <c.L MA- 621940
Home Owner Address ,
Homeowner
Telephone -
Present Mailing Address 1 t
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
him who does not possess a licarse,provided that the owner acts as supervisor.
DEFINPITON 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 Moro
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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE
,APPROVAL OF BUILDING P!S ECTOR
See other side for state code
I
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
1',I:: Mlrl ' Illv.'11 1_�q',1J11\I..IIV�1'IIkLT .)•\II\I. N.\��11111J1 •.f° - >
.f .,.•II rrf:'1.9 .j4.,},y . r\r:v;s.;,a'sxl
construction DebrisDxlPM t
libralljon ovtion wok)
In accordance with the sixth edition of the state Duilding Code, 780 CMR section 111.3
Ocbris, and the provisions of MGL c 4U,s 54: MGL c
is issued with the condition that the debris rnulting from
Building Permit M_,_ _: r1 Ucenskd waste disposal facility as defined by
this work shall be disposed of in •a prope Y
I 11. s 150A.
The debris will be transported by:
1 coma of hau r)
'1'Ite debris will be disposed of in :
(,,am of U1 1�
6, U..A —
I;,aam.11f fxlluy/
.I�nature of Iwrmit,ipplicaru
Jate