241 NORTH ST - BUILDING INSPECTION (3) 4 -70 , ct�p
'file Commonwealth of Massachusetts CITY OF
9 Board of Building Regulations and Standards SALEbI
Massachusetts State Building Code, 780 CMR
� Revised,Llur 2011
( Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For.Offtcial JJse Only
Buildingr Permit Number: Date A plied:
l Building Nlicial(Print Name) Signature Date
SECTION 1:SITE►NFORNIAT11W
1 Property Address: 1.2 Assessors biap&Parcel Numbers
I.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
"tuning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§5d) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public}, Private❑ Zone: _ Outside flood Zone? Municipal❑ On site disposal system ❑
9F Check if yesCl
SECTION2: PROPERTY OWNERSHIP"
2.1 Owner'of Record:
54iIV/ti1"7 (U*L--n3 ) sJ9CJi /^ t7A
NN me(Print) City,State,ZIP
1 -1/ .v )2fiN q7,-• 039.,a
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building)d Owner-Occupied ❑ 1 Repairs(s) ❑ I Alterntion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed 1Vork-: eJ
,�tl t=Lc�n 12N
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
1. Building S F; C.9W,aC7 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S C3(7.tso ❑Total Project Costs(Item 6)x multiplier x
3. Plumbing S IjCpo. Lr V 2. Other Fees: S
d.Mechanical (FIVAC) S List:
5. ,\lec"mienl (Fire S Total All Fees:S
Stippression)
Check No._Check Amount: Cash Amount:_
6. Total Project Cust: SIC. 000 t00 ❑Paid in Full ❑Outstanding Balance Due:
Ic71LA (vl(>�LLT� 10 2a1 Q�p(��1
ti
SECTION 5: CONSTRUCTION SERVICES
5A Construction Supervisor License(CSL)
License Number Expiration Date
N;une of CSL Huller List CSL Type(see below)
Type Description
No.and Street U W,tr 'y
Ouildin s u -to 35,000 cd111.
R 1&2 Fa mil DwellinCity/Town,State,ZIP M RC verinWS dSiJinSF urning AppliancesI
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Dale
IIIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town, State ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT'(M.G.L:c. 152.4 2SC(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 APPLI ES FOR BUILDING.PERMIT
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's None(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,) 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.
lv-;�O-l�
Print mcr's or Aut wrized Agen (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 nut have access to the arbitration
program or guaranty fund under 1I.G.L.c. 142A.Other important information on the HIC Program can be found at
wvww mass eov'oca Information on the Construction Supervisor License can be found at w%v%v.mass.,!ovAlys
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. 11.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of htdf/baths
Type of heating system Number of decks/porches
'Typeofcoolingsystem Enclosed Open
i. `Total Project Square Footage"may be substituted for'Towl Project Cost"
CbYCFSAUA 1 AZAaffmi
BLUUMDAPAREMW
12DWs�3witm
$OO�itiBYLlltt9471 Faz N49�6
CFP[BIlQfi�BIITY/�tp1�K;O�pV
Construction Debjs Dispose►/Affldovit
(required forall demolition andrenovatfon worki
in wm dmw with the"edltlon of Me Stall&rll W-Code,780 tU,sMW lnj debt
and the providers of MGL ce,S S4;&djft Fern*# 0
Is Issued wish the
oondfan t Wdo debris restdtt from this Work shelf be dtsposed of In a properly ftww "
waste depost bdffty as defined by M6L c ill,S 15k
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name offacflitY)
�'Ewl3�2y S�-• 1� ql?Ur�y
(address of feci tty)
Si nature of apph ant
)v U,
Date
3 s QTY OF SALEM, MASSACHUSE M
BUILDING DEPARTMENT
ksty 120 WAS-IINGTONSTREET,3ft0FLOOR
nL.(978)745-9595
KINMERLEYDRISOC)LL FAX(978)740-9846
MAYOR TWMAS STTIERRE
DIRECTOR OF PUBLICPROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date
Job Location of y/, Any u2 f-H S�
Home Owner Address v2 / til�D v S f
Present Mailing Address_ $ k4'— Ac
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 /
APPROVAL OF BUILDING INSPECTO