16 NORTHEND AVE - BUILDING INSPECTION CA';�-. 61-
20 .
The Common �]IC ESTa
ITY OF
Board of Building a i nd andards/ ALEM
Massachusetts State Building Code, 780 CNIR d,Wr
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(� d d/ar 20/!
Building Permit Application To CRu!'! ��Palr, RenovateSr Demolis
One-or Two-Family Dwelling
\ This Section For Official Use Only '
Building Permit Number: Date.Ap lied '
Y� f Z
Building Official(Print Name). S' :at, _ Dat
SECTION t:SITE INFORMATION
I Pro r ddress: 1.2 Assessoro Map g Parcel Numbers � 60
1 Gc d=d r�Je, p
1.1 a Is this an accepted street9 yes X no Nlap'Number Parcel Number
—�
1.3-zoning Information: L�LPro ert Dimensions:
i C
Zoning District Proposed Use Lot Area(sq tl) Frontage(1)
1.5 Building Setbacks(it) Q, ( +tH vl M.. y
Front Yard Side Yards Required Provided Required Provided Required16 Water Supply:(M.G.I.c.40,§54) 1.7 Floo Zone Information: 1.8 Sewage Dis��TT Zone: Outside Flood Zone? Munici al�y On Public Private❑ Check if es❑ p ^
SECTION2: PROPERTY OWNERSHIP!`
2.1 Ownert of Recor IV
r?Ant�y A� no' 3.� AI �v✓1 1 !
t��line(Print) / City,State,ZIP
tl%r
No.and Sired Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK](check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied X I Repairs(s) ❑ Altemtion(s) Addition O
Demolition Accessory Bldg. ❑ Number of Units: Other ❑ Specify:
'ef Description ot'Proposed Work=: 2O
m e ) M o0
SECTION a:ESTIMATED CONSTRUCTION COSTS
ltct Estimated Costs: Official Use Only
Labor and Materials -
1. Building S Q 4060 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S Cl Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 1,9ther Fees: S ((� i- � ��� r
q. Mechanical (FIVAC) S List: v ✓'�, ✓
5.iMcchanical (Fire S Total All Fees:S
Su ressiun)
Check No. Check Amount: Cvlt Amount.
6.Total Project Cost: S ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
I• �. _ License Number Expiration Dale
Name of CSL Mulder .r
List CSL'fype(see below)
"rype Description
No.;rod Street
U Unrestricted �uilJin s u to F5 000 cu. 11.)
R Restricted I&2 F:unit Dwellin
` Cityrrown,Stale,ZIP M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Buming Appliances
1 Insulation
Tcle hone &nail address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
_ HIC Cumpany Name or HIC Registrant Name
No.and Street Email address
City/Town,State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G,G 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........... ❑ t
SECTION 7a:OWNER AUTHORIZATION:TO BE COMPLETED WHEN.'.
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERDIIT
I,as Owner of the subject property,hereby authc rize—LJ; d 4� �' (�e) �Vl
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
9 z, 'o?
-Print Owner's Notne(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 my knowledge and understanding.
zgg
Print Owner's or Authorized Agent's :one(Electronic Signature) Ste
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 nnr have access to the arbitration
program or guaranty fund under�1I.G.L.c. I42A. Other important information on the HIC Program can be found at
www mass eov'oen Information on the Construction Supervisor License can be found at wwsv-mass. ov:!dL .
2. When substantial work is planned, provide the information below:
'fotal fluor area(sq. R.) ~ .(including garage, finished basement/attics,decks or porch)
✓) Gross living area(sq. It.) Habitable room count
Number of fireplaces C3 Number of bedrooms
Number of bathrooms Number of half/baths
Number of decks/porches
i� system
fype of heating sys --�
Type of cooling system Enclosed Open_
3. "total Project Square Footage"may be,ubstituted tin"total Project Cost'
QTY OF SALEM, MASSACHUSETTS
�y�III BUILDING DEPARTMENT
11\� j�% 120WASFUNGTON STREET,3RDFLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KIMBERLEY DRISCOLL
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMIvf[SSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
I �Date / ,� (�
Job Location `c,o d d � f ern I b 1 c1l
Home Owner Address Q6 `�yI �� V 1 'eJS V—' l
f�
Present Mailing Address C SPY �' n
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
� QrTY OF SALEM, MASSACHUSE M
I�l
BUILDING DEPARTMENT
120 WASIWGTONSTREET,3'mFLOOR
TEL.(978)745-9595
KIMBERLEYDRISOOLL FAX(978)740-9846
MAYOR THomAs ST.PmRRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING 00WvMSIONER
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:
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
Da e
File Number:201400767
EXHIBIT"A"
LEGAL DESCRIPTION
The land in said Salem,Essex County,Massachusetts,together with the buildings
thereon,situated at and known as 16 Northend Avenue, Salem,Essex County,
Massachusetts,bounded and described as follows:
SOUTHEASTERLY By Northend Avenue,fifty-eight(58)feet and eight(8)
inches;
SOUTHWESTERLY By land formerly of Ballard,now or late of Coblents, .
ninety-seven(97)feet and three(3)inches;
NORTHWESTERLY By land now or late of Cressy,fifty-seven(57)feet;and,
NORTHEASTERLY By lot numbered sixteen(16)on the plan hereinafter
referred to,and now or late of Donaldson,ninety-seven
(97)feet and nine(9)inches.
Being lot numbered seventeen(17)on a plan entitled,"Plan of the Symonds Estate on
North,Buffum and Northend Streets in Salem,"recorded with the Essex South District
Registry of Deeds,Book 1033,Page 300,said plan actually recorded as the second un-
numbered page after said page 300.
For Title reference see Deed recorded immediately prior hereto.
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