39 NORTHEND AVE - BUILDING INSPECTION (2) y --- I'lie C'onunonwealth of"bLlssachuscus
board of Duilding Regulations and Standards CI IN OF
Massachusetts Stott: Building CuJc, 730 CMR SALEM
/1,•ri,trd.l btr'rl//
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(U Building Permit Application To Construct, Repair, Renovate Or Demolish a
I One-or rises-fasnrls Du ellin,l(
This Section For 011icial Use Only
Building Permit Number: Date Applicd:
IluRding 011icial(Print Nmnc) SilKature W Date
SECTION I: SITE INFORMATION
I.1 Properly Address: 1.2 Assessors blop& Po real Numbers
• l�/04.4 ,.,a Ave. _
I.In Is this an acce fed street? ,es no Map Ntmsber Parcel Nunther
I.] Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed(Jse Lot Aron Ivy 11) Frontage(R)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:IM.G.1.e. 40.§34) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public(3 Privato❑ zona: _ Outside Flood Zone? Municipal❑ On site disposals)stem ❑
Check if csO
SECTION 3: PROPER"OWNERSHIP'
Owner'of Record:
5+emu + Chr,,e1L, K b l M 9 OX 7O
ne(I'rinl Cit .. lata.Z.IP
3gi lV,>Av ,,.t 1� 7- 7 0- 137�1 5� r��14i'�6@�mc ll.Go
No.and Street fetephone Y.Inall Address
SECTION d: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ O er-Occupied ❑ Repairs(s) ❑ Alteration($) ❑ I Addition (3
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ I Other ❑ Specily:
Brief Description of Proposed Work' O'
SECTION 4: ESTIIIATED CONSTRUCTION COSTS
Item Estimated Costs: Of11cIAI Use Only
I Labor;rod .Materials)
I. Building S 1. Building Permit Fee: S Indicate how tee is determined:
'. Hccirical $ ❑Standard City,Tw,n Application Fee
❑Total Project C'osl'(Item 6)x multiplier _..--x
). I'IumMag S '. Other Fees: S_
4. Meehan ical ill\ \(') S List•.-- '---- --'----- -- — _.-_ . . .
\ledtanic."I "Fire
�u.vcsswn)
Check Vo, __('heck :\mtnmt: l',uh \mtuutt:
e lbtal Nrnject Cost: ) 0 Rid in Full C3 Outstanding 11.0.mcc Due:
SEC IION .A: CONSTRUCTION SEMI( FS
5.1
1 CV11.4c Nun lber IiNpiration Pall:
Nallic'11,01 liolifer 11,101.
PC
11 Unroiriocd illuilditip kin to
it:,tricted
IW Rtx,fin L.......
AS Window a,
r
t I
Rt"iltill L
d
n
'J I S 7" t d
in
m
SF sulid Fuel 11—;.— A-1;.........
' 11'
I Insulation
1)
I Entail addmsi Donolition
5.2 Registered Hunts Improvement Contractor(HIC)
I I 11C 14,.6tiratioa Nunitvi I
IIC litqibiratiun Nunit".r F N11irillion W19
IIIC Coniplut) Name orIlIC lUgi.4trum Name address
No. mid Street [:mail address
City/Town, State.ZIP relcPhone
SECTION III WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152. 1 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 .......... 0 No...........C!
SECTION 7s: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I. 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 0micit's Naine(EIMIrunic.4itinature) Date
SECTION 7b:OWNEMOR AUTHORIZED AGENT DECLARATION
[Byenteri my name below, I hereby attest under the pains and penalties of perjury that all of the information
Contal I-4M in this application is true accurate to the best of my knowledge and understanding.
AkAo 46. ". , (./.?/Aa
()%%Ilc 14amc wwrtlitic Silikullurg) Dow
()""c if -
NoTES:
I. \n 0\"ier\Ou obtains a building permit to do his her own work,uran owner who hires an unregistered contritour
(out registered in the Hume Improvement Contractur(HIC) Program). will nu have access to the arbitration
program or guanint) fund undcr.M.G.L. %:. 141A. Other important information on the HIC Program can be l'ound at
01.1'.1 g"" ,, I Information on the Construction Supervisor License can be found at it,1, 1p,
2. \%lien substantial work is pl;uitied, prow ide the hilbrinaflon below:
focal flour area(iq. 111 1 including garage. finished basement attics,ducks or porch)
Gross hiving area i iq. It I Habitable room cut"It
\Limber ot'bedrooms
\timberot hadirooms of hall balks
1),:ot'llemilIg 3),1011 NuntherofJecks, porches
pe 1'ilOoscd 01wil
I i'I'll Project 1;kltiart: Fool,icc- ii;i% he tihiottitvd l'or *lotal Proi"I 01,1"
y
CITY OF Smzm
PUBLIC PROPERTY
DEPARTMENT
u 1aW311.L_..,..ri
w•'O• �]o s.wK.-roM sr•aar•l�aaa.w..ow sum Ot fro
ML 9-9-7+9.9sss . K..a r•fr,a-iw
HOMEOWNER LICENSE EXE.1 MON
P1ew /mist
Date �1
Job Location 32 Lw*wrLc Auc _ SaLy", ✓ E ot47b /
Home Owner Address 5a✓ -
Homo Owner Telephone 1017- 7 1371
Resod Mailing Address 5/..ru_.
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or teas and to allow such homeowners to engage an individual for
hire who does not possess a licenso provided that the ownar acts as supervisor.
DE INMON Of HOMEOWNER
Person(s) who owns a pared of Lod on which WAs resides or Intends to reside. on
which then is, or is intended to bs6 a one or two fishily 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
"homeownd'shall submit to the Building O0144 on a forth acceptable to the Building
O@lcial, that he/she be responsible for all such worst performed under the Building
Permit I I ,
The undersi vied "homeownce assumes responsibility for compliance with the State
Building Code and other applicable bylaws and regulations.
The undersigned "horeowner"certifies that hdshe undentands the City of Salmi
Building Department minimum inspection procedures and requirements and that he/she
Will comply with said procedures and requirements.
HOMEOWNERS sta-m-rum �i � 6t .G, / •
APPROVAL OF 3UILD NG NSPECTOR t/
See other lids for state code
,- CITY OF S.V-&Ni, A1SS.1CFiL'SETI"S
f3L LONG OEP.1AntF,\T
120 WASHNGTON 3T12Xr, J'O FLCCA
IEL. k978) 745.959!
KIMBERI Y OUWOLL FAX(978) 740-984
NUYOI! Ma.%W ST.PMA"
Oinscres OP Pt HUc PROPlRTY/8lancgG commSSIOV Ell
Construction Debris Disposal Attidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR sectio
Debris, and the provisions of MCL a 40, S 34; n i 11.1
Building Permit a is issued with the condition that the debris resulting m
this work shell be
l 11, S I JOA. disposed of in a proro
Pettyperly licemed waste disposal facility as dedncd by NICE c
The debris will be transported by:
Na obol'-J- � H
(name-of_h ulaq_____
The debris will be disposed of in :
(n.me of hcNl y)
Si.)ON
(,ddrefr at `1c hNy)
� tiro ur;,ermit ipphc�nt
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