207 NORTH ST - BUILDING INSPECTION The Commonwealth of Massachusetts
it Board of Building Regulations and Standards FOR
,h ML1N1('IP:\LI'll'
i I�� Massachusetts State Building Code, 780 CMR. 7 edition t)Sp
r Building Permit Application To Construct. Repair, Renovate Or Demolish a Rcrised J(1nmu,'
One- or Tiro-Fanny Dwelling 1, 2008
This Se n For O ficial Use Only
fSignalure:
g Permit Nu r: at Applied::
Building Cummissiune nspe'tur u BuilJin Date
SEC SITE INFORMATION
i
1.1 P o erty Address: 1.2 Assessors Map & Parcel Numbers
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1.1a 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 R) .,. Frontage U't)
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, 554) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Public[3 Private❑ Check if yes❑
SECTION 2: PROPERTY OWNERSHIP[
2.11w�3�o ecor .l�� ��-
Name(Print) \\ Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction ❑ Existing Building T1
Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work'
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SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials)
I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost (Item 6) x multiplier��x
3. Plumbing $ 2. Other Fees: $ i
4. Mechanical (HVAC) $ List: C `
5. Mechanical (Fire $ Total All Fees: $
Suppression)
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date e� , a
Name ol'CSL- Holder List CSL Type(see below)
Type
Description
Addre U Unrestricted(u to 35.000 Cu. Ft.)
6 `��y R Restricted 1&'_' FamilyD%%ellin
Sign- ore Mason Only
Residential Rooling Covering
Telephone WS Residemial Window and Siding
SF Residential SuhJ Fuel Bununa -\ lhanve llblallatlon
D Residential Denwhuun
5.2 �teglstered Impr etnent C ntractor(HIC) O
�CR.,rti I`i �e n C fi r,
HIC Compu�; •me or egutrmt Name Registration Number
A ress ! ��'��1�
��`,L5_ Expiration Date
Signature one
SECTION 6: RKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. S 25C(6))
Workers Compensation Insurance affidavit must be co pleted and submitted with this application. Failure n) provide
this affidavit will result in the denial of the Issuance f the building permit.
Signed Affidavit Attached? Yes .......... No ........... Cl
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 l O.!//� �- to act on my behalf, in all matters
relati work authorized by this building permit[epplication.
Df A,,oe-
a6re of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I , as Owner or Authorized Agent hereby declare
that the statem nd information on the bgregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Nawr
Signature of Owner or Authorized Age Date
(Signed under the pains and penaltiWof jury)
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 fA have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115, respectively.
2. When substantial work is planned, provide the information below:
Total floors 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 cowling system Enclosed Open
3. 'Total Project Square Footage" may be substituted for 'Toial Project Cost"
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CITY OF SALEM
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•.' r A PUBLIC PROPRERTY
DEPARTMENT
Il I '�'8--a;.i;•g � I \�: 'J'8 '�,;- S JIB
Construction Debris Disposal Affidavit
(required liir all demolition and renovation work)
In accordance ith the sixth edition of the State Building Code, 780 CMR section 1 1 1.5
Debris, and the provisions of'v1GL c 40, S 54;
Building Permit it 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
I11. S 150A.
The debris will be transported by:
'name of 1 uler)
the debris will be disposed of m .
(name w facility)
taJJress of lacilim
�ILllatui'e Ot ImA It apt I nt