11 NORTHEY ST - BUILDING INSPECTION (2) 4 $25 C-F.Sr-( 00-3x34tas
The Commonwealth of Massachusetts liSK RW OF
Board of Building Regulations and Standard SALEM
Massachusetts State Building Code,780 CML$U, J S eva Mar 2011
� Building Permit Application To Construct,Repair,Renovate Or)5emo�i3°h 4
One-or Two-Family Dwelling
7 is Secgon Fur OYti-AW,Use Onl
l lied;
Building Persth Number*,
e APP
s� sofficial&riatName> Sj
>aEcrloava:sITE INFORMATION
1.1 Pro rty Address: 1.2 Assessors Map&Parcel Numbers
,h
1.1 a Is this an accepted street?yes no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zouing District Proposed Use Lot Area(sq It) Frontage Ul)
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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Checkifyes❑
SECTION 2: PROPERT'YOWNERSWP'
2.1 Owner'of Record: / wl C)/Q,7 e)� -
eiL
Name(Print) City,State,ZIP
// Now iP�z S� /r°r,r Ail 4 9i�7rn �0,52 a.,,, f z(J lJt;-I}rr- dY c�
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(Dheck all that apply)
Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
New Construction 13 Exist ng Building E3
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work :
SECTION 4:ESTIII7ATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials
1.Building $ 1. Building Permit Fes:$ Indicate how fee is determined*
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost?(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
ca
4.Mechanical (HVAC) $ l v `
5.Mechanical (Fire $ Total All Fees:$
Suppression) -
check No. Cheek Amount: Cash Amount:
y 6.Total Project Cost: $ C6 ❑Paid in Full 13 OutstandingBalance Due.
\ M(-\It_m�VD -T' C�J cam.
SECTION 5: CONSTRI]MON.SERVICES
5.1 Construction Supervisor License(CSL) ,
License Number Expiration Date
Name ofCSLHolder
Lis[CSL Type(see below)
No.and Street - -.Desmtpnon
U I Unrestricted(Buildings up to 35,000 cu.ft.
R I Restricted 1&2 Family Dwelling
City/Ibwn,State,ZIP M I Masonry
RC I Roofing Covering
VWindow and Siding
Solid I=]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 G:WORKERS'COIt4FENSA'IT4M PMRANCE AFFHIAVIT(ALG:I:a 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...........❑
SEC"I ION is:OWNER AUTHORIZA TO BE COAOLETEA WHEN
OWA]ER'S AGENT QkCO ._ CT R 1FOR HUMPING
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 Nahe(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT I}ECLAAATION
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.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES
1. 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 not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important infomtation.on the HIC Program can be found at
wlvw.mass.eovloca Information on the Construction Supervisor License can be found at MMM.mass.gov/dp-s
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type 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'
,4 CITY OF SALEM) MASSAaiUSE TTS
BUILDING DEPARTMENT`
�0 ry 120 WASHINGTONSTREET,3" fto R
\� TEL. (978)745-9595
KIMBERLEYDRISCOLL FAX(978)740-9846
MAYOR TrIOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BURDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT.,
Date 7`/3 ' 6
Job Location �—
Home Owner Address !/ 1t>01'"47 _
Present Mailing Address 44-71.4 i _ a-A--)
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 SIGNATUR
APPROVAL OF BUILDING IN9ECTOR
2016-07-15 16:09 Phil Richard Ins 9787741318 >> 9787409846 P 1/2
Phil Richard Insurance,Inc.
27 Garden Street Unit IB Aa
Danvers,Ma 01923
(978)774-4338
Fax(978)7744318
M,
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