30 NORTHEY ST - BUILDING INSPECTION (3) The Commonwealth of Massachusetts
eg Board of Building Regulations and Standards
Town of
p�
V➢f % Massachusetts State Building Code, 780 CMR, Th edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
\ One-or Two-Family Dwelling
\� his Section For Official Use Only
(� Building Permit Number: Date Applied:
�1 1 Signature:
Building Commissi d Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Pro erty Address:. 1.2 Assessors Map& Parcel Numbers
Aey
1.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(R)
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 Di posal System:
/ Zone: _ Outside Flood Zone?
Public H Private❑ Check if yes0 Municipal eon site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: 3o
Name(Print) Address for Service::) I
� 1 97k-3 97- 15_FZ
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Eri Owner-Occupied 01 Repairs(s) 13 1 Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify:
Brief Description o Proposed Work': o ev
O Yt -1
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical g ❑Standard City/Town Application Fee
❑.Total Project Cost (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Su ression Tidal All Fccs: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ � ad 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTWCYiON SERVICES `
5.1 Licensed Construction Supervisor(CSL) S /' p LPL,? t p a01
,� "- L License Number / Expiration Date
Namc of CSL- Helder/ d v10 ,t`J / List CSL Type(see below)
Address / (/�I Type Description
SW 0 19 U Unrestricted u to 35,000 Cu. Ft.)
I ( d R Restricted 1&2 FamilyDwelling
Signature _ '1 M Mason Only
Z —I RC Residential R noting Covering
Telep a Qi WS Residential Window and Siding
/ \vlvR"cw" SF Residential Solid Fuel Burning Appliance Installation
fit\ D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Dale
Signature Telephone
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 .......... ❑ No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
r3 = �
1, T , 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.
Si amre of Owner Date
SECTION 7b/:,OLWNERt OR AUTHORIZED AGENT DECLARATION
(O
1, �CJY-2a n7'—I , as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf. / ri Print Name ` //4'0 Z O O z7
Signature of Owner or Authorized Agent Date /
(Signed under the pains and penalties of perjury
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 information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) 9 X 4 z (including garage, finished basement/attics,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"
CITY OF &UE-NI
PUBLIC PROPERTY
DEPARTMENT
u,a�auti o-w .L
Nwroa 130 WADOPOCTON STMEr•SA►M%UISAGIUSCM 01970
TEL 975-74S•9S" • FAX 974740.9&4
HOMEOWNER LICENSE EXEMPTION
Please Print
Date 0 6 8
Job Location 30 A)c) l S
Home Owner Address o 5
Home Owner Telephone Z z -
Present Mailing Address O h
The current exemption of"Homeowners"was extended to include owner-0ccupied
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.
DEFINMON OF HOMEOWNER
Persons) 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requireme ts.
HOMEOWNERS SIGNATURE �,
APPROVAL OF BUILDING INSPECTOR
See other side for state code
- -7 .
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
construction Debris Disposal .affidavit
(required li,r all demolition :old renovation wurk)
In accordance ill, the sixth edition of the State Building Code, 780 CMR section I 11 5
Dcbris, and the provisions of\,1GL c 40, S 54;
Building Permit it is issued with the condition that the debris resulting from
this work shall be disposed of in a property licensed waste disposal lacility as defined by MGL c
111. S 150A.
The dehris will be transported by:
(�.se V 1`C)[�
1 name ut hautar)
lie ddcbris will be disposed of*in
li t o I �a "�
I namr ut IaeJny) .
1, rc.. ur lacilnyl
H L'I WIUI I' tlp:nun al+p hcant
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