202 NORTH ST - BUILDING INSPECTION (5) T13 - 1� - q5 z 25 CP\5H
The Commonwealth of Massachusetts
g`
Board of BuildingRegulations and Standard CITY OF
SALEMassachusetts State Building Code,I 'FW ONAI�SERVIC $Revised ti1ar4701!
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or 7lvo-Family Dwellin
This Section For Official Use my
Building Permit Number: Date App ' d: �-
Building Official(Print Name) Signature J Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
I.I a Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
/_citing District Proposed Use Lot Area(sq 11) Frontage(It)
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:
Public Zone: _ Outside Flood Zone'?
f� Private❑ Clieck if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Oner'ofRecoV �CHE S/f"�PZy G�Ff�r'7 b7 ,,(Ce
Numc(Print) City,State,ZIP
20.2- P0,06 5j g7r7V5'Y079
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction jj Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work`: �';,4AC G �Lf}/� ON .2 arch
/IeDbACG L/ 1?65T 9N�) T'Vo Se7s e�t9c-C
4A7-n4 -6 /tit/.) *ri m
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ I. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard Cityfrown Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: S
4. Mechanical (IIVAC) $ List:
5. Mechanical (Fire $
Suppression) 'Total All Fees:
!,. Total Project Cost $ 3,GCJ 60
Check No. Check Amount: Cash Amount:
❑ Paid in Full ❑Outstanding Balance Due:
4
(Pt
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
G'i%l iq License Number Expiration Date
Name of CSLHulder]ii "AtIt.. I J.1-1011
List CSL Type(see below)
No.and Street :jl 'k k,` f AN gig! Type Description _
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
1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
FIIC Company Name or IiIC Registrant Name
No.and Street Email address
city/Town,Slate,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION 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
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
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below,
1 hereby attest under the pains and penalties of perjury that all of the information
cone ned in tis true and accurate to the best of my knowledge and understanding.
print Owner'. 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 M.G.L.c. I42A.Other important information on the HIC Program can be found at
www.mass.aov/oca Information on the Construction Supervisor License can be found at www.ulass.eov/dps
2. When substantial work is planned,provide the information below:
Total floor 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"
CITY OF S'V.ENf, itiLusikCHUsETTS
BLILOLNGDEP:IRTILENT
130 WASHCYGTON S 'D
TEL (973) 735 595 FLaoa
F.LX(978) 7.1Q 9845
1CI1tHE12L.EY DRISCOLL
NLAYO,11 THonAs ST.PIE&M
DIRECTOR OF PUBLIC PROPERTY/BLILDLNG CONNISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixdl edition of the State Building Code, 730 ChIR section t 11.5
Debris, wid dIe provisions of tbtQL c 40, S 54;
Building Permit tk is issued with the condition that the debris resulting &am
this work shall be disposed of in a properly licensed waste disposal facility as defined by rVIGL c
l t t, S 150A.
The debris will be transported by:
y GU(lA-`�/7 SD L l j� Ncf
(namcofttaufur) _
The debris will be disposed or in
..----- (narne of racdity)
---__(a—Id ras.—So f facility)
siyuaturc fpamitappficmtt
J.uc --
CITY OF SALEM, NWSACHUSETTS
BUILDING DEPARTMENT.
(' 1t frl 120 WASHINGTON STREET,3RDFLOOR
'I'EL. (978) 745-9595
FAX(978) 740-9846
KIMBERLEY DRISCOLL
MAYOR T SOMAS ST.PIERRE
DIRECTOROF PUBLIC PROPERTY/BUILDING CON AIISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date
' Job Location 3C,)- No&th s/ 5t7-�tA4 A*
Home Owner Address C ry�^.A-Yk 52- $17-lPn4 /A-
Present Mailing Address j Ca /Yo/o% Sj Salem MA-
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 cl4MK1
APPROVAL OF BUILDING INSPECTOR