210 NORTH ST - BUILDING INSPECTION (2) 1�14 The Coinmouwealth of Massachusetts CITY OF
Board of Building Regulations and Standards
I , Massachusetts State Building Code, 730 CNIR SALEM
� Revised Mnr 2011
V Building Permit Application To Construct, Repair, Renovate Or Demolish a
a One-or Two-Family Dwelling
sSecttonForb. icialUsti-0nly ' 4
Building Permit Number: Date pphe i>, f
Building Official(Print Name) Signature. D. e
SECTION 1:SITE7tNFORINIATION
1.1 Property Add ess: L2 Assessors Nlap& Parcel Numbers
Z/ o Z s7Z-
l.la Is this an accepted street?yes r/ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(R)
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❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yesCI
SECTION 2:, PROPERTY OWNERSHIP
2 Rt : Gr / P
.4 .
Name(Print City,State,ZIP
3 �.����-�
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSER WORle(check all that apply)
New Construction ❑ Existing Building Cl Owner-Occupied ❑ I Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brie escrjp nn of�7c g�k1. —
SECTION 4: ESTINUTED CONSTRUCTION COSTS
Estimated Costs:
from Labor and Official Use Only-,
Materials
1. Building ; I. Building Permit Fee:5 ` Indicate haw fee is determined:
2. Flcctrical $ CT.Standard,City(rownApplicationFee,
❑'rotal Project Cost(Item 6)x multiplier x
3. Plumbing i 1. Other Fees: .S
1. Meehanic,tl (IIVAQ S List:. \
i. ,,\Iech.urir.tl (Piro -
i_nr, rresiun)_-- ---
rotal All Fees: S
�c..�i Check No __Check Amount: _ l':uh \uwuut
I - --
� IlIfal Project Cost 3 / GG t ❑ I'ul ut full _ _-_0 011t,tandin.", Il�ilmcc
SEc,rION5: Co YSrRUCTIONSERVICES
5.1 Construction Supervisor License(CSL)
L.iansz Number -�-- —Expiration Date
Name of CSL I(older List CSL rype(see below)
type Description
No. and Street
U Unrestricted Buildings up to 35,000 cu. lt.
R Restricted 1342 Famil Dwellin
City/rown,State, ZIP �bl %riasonr
RC Roofing Covzrin
WS Window and Siding,
SF Solidnsul Fuel Pluming Appliances
I Iation
1'cle hone Email address D Dzmolition
5.2 Registered Hone Improvement Contractor(IIIC)
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 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 .......... 0 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 7h: OWNERI OR AUTHORIZED AGENT DECLARATION
By entering my ame below, I here at rider the pains and penalties of perjury that all of the information
contai it appli•ati is ue; a• urate to the best storm
knowledge and understanding.
/ fit Owner's or: uthurimd Agant's N.Ime(EIcc«unic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires;m unregistered contractor
(nut registered in the Boma Improvement Contractor(HIC) Program), will not have access to the arbitration
progr:un or guaranty fund under\LO.L. c. 142A. Other important information on the HIC Progr:un can be found at
www nrts<.aov oca Information on the Construction Supervisor License can be found at www.mass.-7o%ILU
2 When substantial work is planned,provide the information below:
Total tloor area(,q. It.) _(including garage, finished hasemenNattics, decks or porch)
living:itea(;y. 11.) PP:abit:tblz nnan count _--
Nllm'erof lireplacus..-------__-- Number of bcdrunms
- . .. -
---
Nuntherotbathrooms ___-- NumhzrofhalEbaths -._.._-.---
-- -
- ---
I'cpe of ha.ltinq iy;tcna Number of,lxks/purcl c; --_--
Lnelo;ed prn
rt iyu.lr,: Fri,rt.,^a" nl.ly hr ;Ilb;titut: l t�,a'I„rll I'rnjdcl lint --- — ----
y
CITY OF S.U-F.Nf
PUBLIC PROPERTY
DEPARTMENT
V 10•alfY yir'.r.
w.w i re v�.+w ssuar•suay.woaor.rar7s of•.
RL 9"1.715-95" •FAM 93.7ie.964
HOMEOWNER LICENSE EXE.Mrrlo,V
Ptew iiriet
Date Z ��
lob Locadoss
Home Owaso,Addreas
Home OMM Telephone
Pinned Mfg Addttaae , f�� � .
no current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Unite or fees and to allow such homeowners to engage an individual for
him who don not Padua a IicmM,provided that the owner acts ar aupatviaotr.
DEFINMON OF HOMOWNER
Persons) who owns a pored of land on which hdshe rs aidae or Intmsde to reside. on
which them iq or is intended to be;a one or two family dwelling, attached or detached
rtructura accessory to,such use and/or farm structures. A person who construct@ more
than one home in a two year period JW not be considered a homeowner. Such
"homeownd°shall submit to the Building 001ei4 on a form acceptable to the Building
Ofl7ci4 that helshs be responsible for all such work performed under the Building
Permit.
The undersigned "homeawnd'"Imes responsibility for compliance with the State
Building Coda and other applicable bylaws and regulations.
The undenigned "homeowner'certifies that hNsha undmtands the City 91
Salem
Btiilding Department minimum inspecdom p edtsra and requi an that hdshe
.vill comply with said procadttra � �\
HOMEOWNERS SIGNATL
APPROVAL OF BUILD . 'SPECTOA ,
See other side far state code