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241 NORTH ST - BUILDING INSPECTION 4-zr fhe Commonwealth of Nlassachusetts CITY OF Board of Building Regulations and Standards SALEM i l Massachusetts State Building Code, 780 CMR y,J ReviseJ.Llur 20/1 Building Permit Application To Construct, Repair, Renovate Or Demolish a Ore-or Tivo-Family Dwelling This Section For Official se Only ' Building Permit Number: Date ppliedi Building 01111cial(Print Name). signature T Date SECTION 1:SITE INFORMATION' 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 1.I a Is this an accepted street9 yes_ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: "Coning District Proposed Use Lot Area(sq 11) Frontage(11) 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 es❑ SECTION 2: PROPERTY OWNERSHIP!` 2.1 Ownerl of Record: t�tlme(Print) City,State,ZIP No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORKS(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Altemtion(s) ❑ Addition ❑ Demolition ❑ AccessoryBlJg.❑ NumberafUnits_ Other ❑ Specify: Brief Description of Proposed Work': ,A eJ b-eP. S9c.-C2 L\ SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Nlateriais) I. Building C ,o I• Building Permit Fee:$ Indicate how fee is Determined: ❑Standard City/Town Application Fee 2, Electrical S C-1CW- 0 0 ❑Total Project Cose(item 6)x multiplier x 3. Plumbing S 2S Qther Fees: S 4. 11cchanic:d (IIVAC) S ©, spD List: S. \Icchanical (Fire S rotal All Fees:S Suppression) Check No._Check Amount: Cash Amount:_ 6. 'futal Project Cost: S �3�C7c? w ❑Paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL holder List CSL Type(see below) No. ;md Street Type Description U Unrestricted OuilJin s u to 35,000 cu. 11. R Restricted 1&2 Family Dwelling Cityfrown,State,ZIP M Masonry RC Roofing 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 No.and Street Email address City/Town,State ZIP Telephone SECTION 6:WORKERS'CONIPENSATION INSURANCE AFFIDAVIT(M.G.1.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'$AGENT OR CONTRACTORAPPLIES 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 Nmne(Electronic Signature) Date SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below,I 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 any knowledge and understanding. Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: I. An Owner who obtains a building permit to Jo his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will nil have access to the arbitration program or guaranty rund under NI.G.L.c. 142A.Other important information on the HIC Program can be found at NVww.mass.LLov!oca Information on the Construction Supervisor License can be round at www•.mass. ov:ldJs 2. When substantial work is planned,provide the information below: 'total floor area(sq. it.) .(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 dumber of half/baths rype of healing system Number of decks/porches rype of cooling system Enclosed Open_ 3. "Foul Project Square Footage"may be substinued fir"'f uud Project Cost" CITY OF SALEM, MASSACHUSETTS BUILDING DEPARTMENT 120WASHINGTON STREET,31DFLOOR TEL. (978) 745-9595 F KIMBERLEY DRISCOLL FAX(978)740-9846 MAYOR TrIOMAS STTIERRE DIREcrOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER 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 111.5 Debris, and the provisions of MGL c40, 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 deposit facility as defined by MGL c 111, S 150A. The debris will be transported by: �1n�fC7 /2)-'C-YCC.7.y[e (name of hauler) The debris will be disposed of in: (name of facility) ,SEA 130D y J'�- 4 (address of facility) Sig ature of applic nt Date CITY OF SALEM, MASSACHUSETTS BUILDING DEPARTMENT 120 NVASFUNGTON STREET Y"FLOOR TEL. (978) 745-9595 Fret(978) 740-9846 KINIBERLEY DRISCOLL MAYOR THONIAS STTIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING CONEvESSIONER HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: Date Job Location A,)V Lf r-/ S!Z Home Owner Address aLy/ lv�olLth/ 5 �- Present Mailing Address oZ c2/4 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 INSPECTOR t7Lt4 S