11 NORTHEY ST - BUILDING INSPECTION �/� / ' �, I'he C'onunomveahh ul'Mussachusctts CI I'1' OF
I a Board of Building Regulations and Standards
Massachusetts State Building Code, 7SO LAIR S.\LIC,\I
Nerued ilar'll//
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or rnn-fiords' Dive iiig
This Section For Official Use Only
x1h
t Number: Date pplied:
A';-4 17ial(Print Name) Signature Owe
SECTION 1:SITE INFORIIIATION
J'hOdress: 1.2 AssessorsSlap S Pu tl Numberce teal sheet? n no blue Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
/using District Prupowd Uw Lot Area fill II) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:IM.G.i.c. 40.154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
ILbltc❑ Prhute❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposals)stem ❑
Check if cs❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Rece d:
;and(Print) City,Slate,ZIP n
1� rUr��l h r c� Sal— R7b-&'o-71 eo52- G c��inYN! {z(y (7p—Art Ord,
Nd.anJ Sheds rdlephune F:muil Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alterationts) ❑ Addition ❑
Demolition ❑ I Accessory Bldg.❑ I Number of Units_ Other O Specify:
Brief Description of Proposed Work': — i(_ k
Ah-e��j rJ tc' �2AzFal ('�(�,�.Asrr3fo
SECTION 4: ESTIALATED CONSTRUCTION COSTS
heal Estimated Costs: OlTlcial Use Only
ILabur curd \Imerials)
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard CityTussn Application Fee
❑Tutal Project Cust'(Item 6)x multiplier _._ x
1. I'Iwnhing S �. Other Fees: S
J—MMI.usical ill1.\('1
�. \lech.wical iFird
Cu +vessiunl S Tutu .\Il Fees: S_
I, Total Project Cosl: S 21 000 Oa Check Vu, _..__( IIscA :\mount: ('_.. _ ,uh rn\mou :
0 Paid in Full [I Oulstanding lial;ince Due:
SEC'l ION 5: CONS I'R(,(:-riON SERVICES
5.1 Construction Supenisor License(CSIT--
I istL'Sl.
kPc Description
Na. and feet
I I n restricted I I Im I di'm ub to 35.000 ol tl
R
%I Nlasoll
RC K,X)fill UINCrIn
WS Window:aid SIU1111
SF solid Fuel 1111ming Appliances
Insulation
1'elc hone Finail address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
111C Ilegistratiun Nurn -r INPiration Date
IIIC Compan) Name or IIIC liegistrunt Ninte
No. and Street Eirluil address
City/Town.State,ZIP relcohone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.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 .......... 0 No...........0
SECTION 7s: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.
(Electronic Signature) Date
SECTION 7b:OWNER' 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.
%whori/ed Agcin'.4 N;me 1 Flevtrikiiic Signaturv) Datc
NOTES:
I. An Owner\Ou obtains a building permit to do his her own %sork,or an owner who hires an unregistered contractor
Inot registered in the Home Improvement Contractor(HIC) Program), will no have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
\\A%1% k .1% 1 Information on the Construction Supervisor License can be found at 1%w, Z11.1,4 It,,
2. %%hen substantial Ivurk is planned, provide the information below:
row lloorarva iscl. n.) 0"Cludilig garage, finished basement attics,decks or purch)
Gross It%ing area(Sy. tIL) Habitable room eotnit
\11111herol'tirvillac" Number kil'bedrooms
\;umhcr ofliall hall's
I peol,heeling S)Stem Nmnhcr ot'de"s, porches
l,C ol,eoolillg ,\NIC111 1,11elosed
I loi,fl Project Square Footage— ma\ be iiibstitutcd 11or ,l'otai Projed Cuss"
CITY OF S.UF. N1
PUBLIC PROPERTY
DEPARTNLENT
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ra.raa49.9599•f%x r.ar+d9s+e
HOMEOWNER LICENSE EXEIMMON
Pkssw hint
Dan
job Location i! Nor-A&&4 \S--k
Hmeo owner Address A, varM emsd c� Met
Home Owner Telephone 97,r- ko-7- R a ,6
Preaent Mailing Address
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 n supervisor.
DEFiNMON OF HO&WOWNER
Persons)who owns a parcel of land on which he/she resides or intends to reside6 on
which there is, or is intended to be6 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 shag 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 inspation procedures and requirements and that he/she
will comply with said procedures and requirements. nn
HOMEOWNERS SIGNATLRE
.iPPROVAL OF BUILDING INSPECTOR
See other side for state code
V
CITY OF S.1 ZNf, NL1ss.1CFi(,'SETI'S
BLttOLVO DEP.+a'nte,�T
iLL �978) 74J-9S9!
Kl%CBFRLBY ORLSCOLL FAX(974 740-9W
.tiUYOIt I kaxw ST.Pts•■■
Dr"4TOt OP PLBLlC PROPla TY 8L tIDCYC CO\p115310\Elt
Construction Debris Disposal Attidavit
(required for all demolition and renovation work)
fn accordance with
ri
Debs, and the sixth edition of the S
the provisions of MCL a 400 9 34; tate Building Code 130 CMR section I Building Permit At is issued with the condition that the debris resulting from
this work shell be disposed of in a properly licemed waste disposal facility as defined by,mGL c
1 11, S IJOA.
The debris will be transported by:
(nurna of hauler)
The debris will be disposed of in :
V Sh t yak
(rJdrcff orA.+h+y)
+ fn.mreofpermif �pp6crnf
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