34 NORTHEND AVE - BUILDING INSPECTION -- -- -- ----1-lie Commrin%%,-allh „I
e li„arJ kit Bulldmg Regulaw,n, .Ind S(.uldards I ! Ilt
\II .\h II' \I II1
\l:u,achu,etI, State 1uiIll ing l',,dr. 7SII('\IR. 7"' cdI11,vl
13uildim_ Perm it :\lrrli eati,m To ( un>tnlet. Repair. Ken,,,.nr l h DCnu,li,h a j K, : „„l 4un„l,
Olw- rrr Tit o-Plumtli"011,Milk!
f I his Seetlon Fi,r t)N Cial 1',e (hdv
Bw Win,' I'll, N I ee -_ —. ll;ue :\pphCJ:
L..— 1 ''11 ( ----- ---- .._.
nw W�nl' nninn�uniry In.l,cclor al Ilu Jdmp Date
SE(:'fION 1: SFI'E l"JOHMA HORN --- -----
1.1 Propert \d( russ: (y Sp�,y n�t 1 ' ,sessurs Nlap & Parcel Numbers
_3�.3�or {���Q� i4re a� -- - - - - - -
LI.I., Is this .urar_ �IeJ sl('eet c, _- nr,_-__ s ._Nuinhrr 1 u.J ♦unlhri
— r
1.3 :?oning Information: d.3 Property Dimensions:
riwit Yard
' 7 5 Buridrng `e'backs (fl) _ _
-- -- Side Y. u Real Paid
Rey,,;;ed j Prukided I'll,iJrJ Hryw:cJ i YI,,,;J.J
1.6 'rLater :Np,y: 00 L; L C. 40, §51) 1.7 Flood Zone Infornttaiion: i.8 Sewage Disposal Systr m j
r "Lune. __ Outside Pill Zone:' I .Y7unml al On ,itc
?.IhLe rra�yy Pnca:e J � P -I
Yam . _— ("heck 'on lie
r SECTiON l: PROPEI2•rY OW'NERSHIPr
.1 (aN m rI of R Cord: —�--
:Wd.0,"!Or icy 6 icf'7c
Telephone —_
SECTION 3: DESCRIPTION OF PROPOSED WORK'(cheek all that apply[
jNewC„nstrueu„n ❑ Esis(ingBuiIdingia Owner-Oecupled ❑ I:ep:e:rr,!;1'�_AI!er,lounl,I ❑ :\JJu ,m n
— —
Dc —� �� Aeeea,a,v BWg. ❑ Number„1 Jnt[s.__ �O'.^.er f$ Spcnly 6� ��S�L
_._- _.---
Fillet
.31._scnpuo❑ ut Prupuaed W;,rl:
1
j SECTION d: ESTIMATED CONSTRUCTION COSTS I
Ilan Official Use Only
'
ll.ahnr.md MAI iialsl.__ I. Building i'en rill I'ee: 5 Indwate h „,. lee ;, JCtel mm,:J.
I IiullJing ) 061J pa I —
❑ Standard Ciro/Town Appheanun Fee -
'. Flcctneal )
O Total Project Gut' I Item b) r multiplier _ s
?. Plumbing 5 ?. Other Fees: 'S
4 .Me,hamcal illy:\CI )
! flee hanl.:l lFire 5 r„tat :\II Fee, S —_- ------
Sn ,ne„i,;nl
l'heek No l 11Cek \m„nuo Ca'h \111 ,mnl
t, fotUl Pnriec[ Cost ❑ Paid in Full ❑l lot>ranJln„ Bal.ln.e Uue
r
raw
SEC"PION 5: CONSTRUCTION SERVO[( U:S� -- ---
5.1 Licensed ('otistrucliou Super%ivl)r IC'SI.I
Lu Cn.i �\wuhir—_---_ F\IIILUI��II lLu.' '
\�uli ul ('S1. II.dJer
LLI l 51. l"pe nii hClm.l
L I IIw,1II.ICJ ,if,LLI ` IN111( it _-_.-
__—__ H Re.0 I.led I. ' F.IIIIII\ I)oiHwie
il_n.uulC \1 1 V\I.I..Iury Onh
Rl RC.IJ:mlal Ko. 11up ('t"Cnn`
frl:phoni t\1 lic"J'nu.J \N iIIJ„I. .IrJ i,Jal
it I 12i.IJ:ln l.d tiuIIJ I .I.I Bw un_I`\1�L i.ul._Ilnl..l l.il: l�
D Hd HJCIIILII D.nwhi".n
5._2 Regislered 11ome Imprurement Contractor 11HCI
MIL'Cuny).mv Name or HIC Hegl,lrant N.ring ----- 12cgl,ttawm Nwi bci
\Jdrei,
F.ynl at l.m Dula
]Ignatur'e relepluntg
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT IM.G.L. c. 152. § 2506u
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to pio,de
this affidavit will result in the denial of the Issuance of the budding 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 In.luers
•c!ative to v,n!: a!whonzed he (his building permit appl wotinn.
Signature of Owner Date
SECTION 7h: OWNFRt OR AUTHORIZED AGENT DECLARATION
1 , as Owner or Authorized Agem hereby Jeclarc
that the statements and information on the foregoing application are true and accurate. to the best of my knowledge and
I behalf. °
Pant Val �— -
Signature of O ner .or . ze Agent Date
ISlmedunderlhe almand a sl ru ) -
NOTES:
I. An Owner (rho obtams a building permit to Jo his/her own )fork.or an owner oho hires :tit uniegl,telcd contra.uu
(not registered In the Home Improvement Contractor IH10 Program), will nt)( have access to the .ubitrauon j
program or guaranty fund under M.G.L. c. 112A. Other important intormation on the HI(' Program .Ind
Construction Supervisor Licensing ICSL)can he hnmd In 780(.AIR Regulations 110.R6 :md I II) RS_ respec n.cic
When .uhsrm ial work in planned, provide the Intirmation below:
F,Ital floors area (Sy. Fri (including garage. finished basentenVattics, decks or por.h,
I (iro,s Ilvmg area I Sy. Ft.) Habnabte room coum --_-----
1 Number of lireplaces __ Number of hedro,-m. .
Number .If ba(litooms ._ Nulnl)et of 11,0111,011
I\pe of he.Ilntg ,v,tem
Ivpe of .oohng
iI .:Folal Project Square Footage" MAN he .uh,tiruled for 'rot.,i Prnlect --
CITY OF S.ULEM
PUBLIC PROPERTY
DEPARTMENT
iu�ncS�DtXt:011
%"VM 130 WAUGNGW M SMW•Shirr.N&%ACN KM 01970
Tn.97WUS-9"S•FAX 976-7449646
HOMEOWNER LICENSE EXEMPTION
Please Print
Date n�
Job LwAtion
Home Owner Address 2u TAcaild.
Home owner present Mailing Telephone
�� r c�ry0 v e Sa nv� Z51�Y1 D
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 who.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 reside@ 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SALEM
A '+
PUBLIC PROPRERTY
DEPART'�IENT
I_': A I\,..,'V S iJ1.l i • 1.\I I \I• \In"1( I. I _I')
III ')'3 Vi.'I.'li 1'\A: 'i�X V:9841 .
Construction Debris Disposal .affidavit
(rciluired li)r all demolition and renovation work)
In accordance \%ith the sixth edition of the State Building Code, 780 CMR section 111.5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I11, S 150X
The debris will be transported by:
(name of hauler) --- - .
The debris will be disposed of in
(namr of laeility)
(address of Facility)
�I_L'11a 10' Ut I)i tll I hall!
late