237 NORTH ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
Massachusetts State Building Code, 780 CMR, 71" edition MUNICIPALITY
USE
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised January
One Two-Fam
ily Dwelling 1, 2008
Thi Sect' For Of cial Use Only
Building Permit Number: Dat Applied: /O-
Signature: PfV-� �)' 1 Vl
Building Commissioner nspect of Bui d g Date
S ITE INFORMATION
1.1 Pro erty Addres : 1.2 Assessors Map & Parcel Numbers
_�-�4- Ai 1 . L. -
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 ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard N I A Side Yards Rear Yard ,N
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 Zo e?
1� Private ❑ Check if yes Municipal �On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP[
1 f�t TQt A ecort
N e(Pri ) Address for Service:l
Cci ?1) 1-�(S - �t`t�S'
Sign Telephone
S TION 3:DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing BuildingRl Owner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑
Demolition Accessory Bldg. fid� 1 Number of Units---L I Other ❑ Specify:
Brief Description of Proposed Work': 'C.- to
_ v
r -+- -fie
�-➢ G2 s.✓ �vaa w M: VA
STRUCTIONCOSTS �' %OVAJycklosr
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ GOQ 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: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire _
Suppression $ Total All Fees: $ 2
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ �QQ ❑Paid in Full ❑ Outstanding Balance Due:
W0. 2
a
SECTION 5: CONSTRUCTION SERVICES
5.1-Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL-Holder
List CSL Type(see below)
Address Type Description
U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6c 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.
Signature of Owner Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
1, i ` \fc ,as Owner or Authorized Agent hereby declare
that the statements 4nd information on the foregoing application are true and accurate,to the best of my knowledge and
beh If.
0_ » C
Prin Nam Wool i
Signa a or uthorized Age, //Date l l I .
Signed an er the ains nd penalties of perjury
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 not 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 I I O.R6 and 110.R5,respectively.
2. When substantial work is planned, rovide t e 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"
' CITY OF SALEM
I. r��� PUBLIC PROPRERTY
DEPARTMENT
.� '; I.C \\ r.�l:•v. .>..III r • \VI V, \I\..\i • .I'I
III 'I'V '73. I„N � I ,\ 'i•9 J_ 'I\76
Construction Debris Disposal .affidavit
(rcyuircd l6r all demolition wiJ renovation work)
In accordance \\ith the sixth edition of the State Building Code, 7S0 CMR section I 1 1 .5
Dcbris, and the provisions of'"I,1GL c 40, S 54;
Building Permit N is issued with the condition that the debris resulting from
this work shall he disposed of in it pruperly licensed waste disposal facility as defined by mGL c
l 11. S 150A.
The debris will be transported by:
SELF
(name ul hauler)
I lie dcbris will be dispuscd ofin
(ua1nC ul Ixlhty)
LulJre.. Ilr Onhlyl
Hllldl Ul L' Ul )i 111111 1 Il.l 1
7/6-Z40 9
{
CITY OF S.u.E.N1
4D PUBLIC PROPERTY
DEPARTMENT
K
NrA1/02 I30 WA94NCTON ST&M 9 c••...`4 %(AQACWSffM019'0
rEL 9'11-745-9S" 9 FAx.9711-740-994
HOMEOWNER LICENSE EXEIMMON
Plow Prtr t
Data /b-Zoo 9
Job Location Z3-7 NO477/ 5T C7/
Home Owner Address Z 33 QM77+ Sr .3ALZM /t 0/9.7
Home Owner Telephone 9-7 8-7qS-9'98 S'
Present Mailing Address 2 3-7 Noori-1 S-T 5ALEM ff At o/97
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
him who don 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 them 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requi v.
HOMEOWNERS SIGNATURE
,APPROVAL OF BUILDING INSPECT R
See other side for state code