241 NORTH ST - BUILDING INSPECTION (2) 383 of cc
2-0q - I �
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR S
/ Revised Mar 2011
Building Permit Application"Co Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Divelling
This Section For Official Use Only
Building gPermit Number: Date.Appliede"
Building OBicial(Print Name). signature "-- Date
SECTION L•SITE INFORMATION
1--.717 Property Address: 1.2 Assessors Map& Parcel Numbers
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 ft) 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:
Zone: _ Outside Flood Zone'? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑ P p y
SECTION2: PROPERTY OWNERSHIP`'
2.1 Ownert of Record:
.` -1",f r.� Cv., -; -r s Jv
N me(Print) City,State,ZIP
L4 - A)o11--trt
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ I Alterntion(s) ❑ Addition Cl
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed \York`: Al ftel Jet/- G v
131—, g5tfXL S��,cc �-��-
r-c—yr�iL- I2 tl'csa cF /act -l.•-�oac.S
SECTION"4: ESTINIATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S _ I. Building Permit Fee:$ -Indicate how fee is determined:
�. Electrical $ ❑Standard City/TownApplication Fee
E70e� i7p
❑Total Project Cost'(Item 6)x multiplier. s
3. Plumbing S j 0 OO•dO 2. Other Fees: S
4. Mechanical (HVAQ S 000-od List:
5. iNlechanical (Fire s
Suppression) "Cotal All Fees:S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $�• t1G70 00 ❑Paid in Full ❑Outstanding Balance Due:
S
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name orCSL [folder
List CSL'Cype(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
C ity/I'own,State,Z I P M Masonry
RC Reeling Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name 'n)
No. and Street Email address
Cit /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 .......... No...........❑
SECTION 7a: OWNERfAUTHORIZATION.TO BE COMPLETED WHEN:
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize
'tr)act on my behalf,in all matters relative to work authorized by this building permit application.
CU--7 a�
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below, f hereby,attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
'S7eP,WA-- Cua � y- �
7ts � % - a- - I -,
Print Owner's 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. 142A.Other important information on the HIC Program can be found at
vvww.mass �>. ov4xa Information on the Construction Supervisor License can be found at www.ntaes."ov!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 SM-E W
PUBLIC PROPERTY
DEPARTMENT
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Vnrcr _ -VWU rt.GWWS+aes. luLa.v..sAnwMMatr'e
tta,s-st�issss . v.,c r.s.ne.�w
HO�LMEOWNER LICENSE E.XZ.%nj0N
Flew Triat
lob Location
Hama Owner Address +
Homy Owner Telephoeo 2 - -
PresentMsoliagAddrae
The current exempdoo of Homeowners"was extended to iochtde owner-occupied
dweuings at two Units or lean and to allow such homeowners to enasse in individual for
hire who.doe not Poe aeas a ueenso provided that the owner acts as sepervisar.
DEFINMON OF HOMEOWNER
Person(s) *be owns a parcel otta d an wbich WAS resides or intends to resid@& on
which there is, or is intended to b46 a one or two ibmily dweuing attached or detached
srru¢tttres aceeswry to such use and/ot farm structures A person who conswicu more
due one home in a two year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Otllci4 on a form acceptable to the Building
OtTlciaL that hash@ be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner'names responsibility for compliance with the Stu@
Building Code and other applicable by64aws arsd retttladans
The undersigned "homeownce certiftes that hashe undentands the City of Salem
Building Ocpautment minimtarn inspection procedures and requirements and that hashe
,vill comply with said procedures and requirements
HOMEOWNERS S[GNAMRS
APPROV,4L OF BUILDLVG !.ti'SPE OR
See Other lids far stile code
CITY OF SALEM, NLkSSACHUSETrS
BUILDIING DEP.%R-n[&NT
N• 120 WASHINGTON STREET, 3"FLOOR
TEL (978) 745-9595
F.kx(978) 740-9846
lIN{ggglEY DRISCOLL
iV YOR TwmjAs ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BCII.DNG CONWISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 11 l.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# 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
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
�e.915 C.)
(address of facility)
1
signature o permit applicant
date
.Irbrisal�J,H: