23 NORTHEND AVE - BUILDING INSPECTION (2) -T6- I4 - / 096 a� l u (z 2-9
^a the Commonwealth of Massachusetts RECEIVED
Board of Building Regulations and Standards INSPECTIONP L SERKITCES'
Massachusetts State Building Code,780 CMR
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2011
Building Permit Application To Construct, Repair, Renovate OrlKoJUN2 One-or Two-Family Dwelling
This Section For Official Use Only
rBuilding Permit Number: ate Applie
ilding 0 cial(Print Name) ,ignature' Date
SECTION I: SITE INFORMATION
Property Address: 1.2 Assessors iYlap& Parcel Numbers
nlo27FFF.Ha
L 1 a Is this an accepted street?yes no Nlap Number Parcel Number
1.3 Zoning Information: --- 1.4 Prg o erly Dimensions:
-Ir e r fl
Zoning District Prolmsed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
12eyuircd Provided Required Provided Require) Provided
1.6 Water apply:(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 ❑
Checkifycs❑
SECTION 2: PROPERTY OWNERSIIIPt
2.1 Owners of Record:
N/Y1,�l2c E Lr c� ^7-2n c tar _ �3 . ha�TN-F�J �► V� ,�}Ci����`tA
mhe(Print) City,Slatc.ZIP
231�o�TN�.vo _ Y7;R-3/7--079 y4j fa r
No.and Street 1'clepltone Form,, ddress
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ NumberofUnils Other ❑ Specify:
Brief Description of Proposed 1Vork--' lcrsLs.,�.�� r-
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Nlaterials
1. Building $ y /� SQ o O I. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical ❑Standard Cityfrown Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (I IVAC) $ List:
5. Mechanical (Fire
Su) ression) $ Total All Fees: $
Check No. _Check Amount:_ Cash r\mount:
6. Total Project Cult .$ / r V(� ❑ Paid in Full ❑Outstanding Balance Due:
1v r 1 b TV cii7 c_0 t� 121
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number L'xpimtion Date
Name of CSL Holder
I I_) r�i I—,, OD 11% piss ype( )
List CSL'f see below
No.and Street Type Description
ll Unrestricted(Buildings u2 to 35,000 cu. ft.)
R Restricted 1&2 Famil Dwelling
City/fown,State,ZIP
M lklasonry
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(IIIC)
FIIC Registration Number Expiration Date
Ii1C Company Name or tIIC Registrant Name
No.and Street
Liman address
City/Town, State,ZIP -..Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(NLG.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.
Print Owner's Name(Electronic Signature) f
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.
�1anclfj Tc)(� 4 2"//
Pont Owner's or Authorized Agents 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 Flonte Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty find under 1MLG.L.c. 142A. Other important information on the HIC Program can be found at
www.nlass._=ov/oca Information on the Construction Supervisor License can be found at www.nlass.eov/dos
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.) (including garage, finished basemendattics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces _ Number of bedrooms _
Number of bathrooms Number of halflbaths
'hype 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 S:VL EM)
' L tiG-1S5 1
• CHLSETTS
8LILIXNG DEP.1RTUFENT
l30 Vq-. SNLNGTON STIREET, 3w FLOOR
Tt.L (973) 7{5-9595
1Q.%(BFRT Ry DaISCOLL F.%-x(978) 74M84,5
NcAyo:a
Sr.PtF-q(tt3
DIRECTOR OF PUBLIC PROPERTy/3C[LDLNG COSLMISSIONEX
Construction Debris Disposal Aftldayit
(required for all demOlition and renovation work)
In accordance with Debris, the sixth edition of the State Building Coda, 730 CP,fR section 111.5
and die provisions of MGL c 40, S j4;
Building permit f#this work shall is issued with the condition that the debris resulting from l 11, S I SOA. ba disposed of in a properly licensed waste disposal facility as defined by ,1,IGL c
The debris will be transported by:
(nantc uClmulcr)
The debris will be disposed of in
t
f
(ndnut or taallity)
� �—/ � JW+ �,f 6 2
(adJress of'tacility/ —�'
fl ylWfUlC U(�CI RIII.I�P(Ii.11 iI
J.ur --
CITY OF SALEM, MASSACHUSETTS
BUILDING DEPARTMENT
a� I° 120 WASHNGTON STREET,3"°FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KIMBERLEY DRISCOLL
MAYOR M-IONIAS ST.PIE RRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CON IISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE
//PRL-ZY��
Date b ? ` rJ� -�{� n / l
Job Location �3 / JQ rt7 , 6n) 14y �FI��`"
Home Owner Address 2,3 /CIO R� e;,, � r1 (//_r cS;O-c � /1-,4
Present Mailing Address 01TNf=�� /4U[ &2c 7
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