6 NURSERY ST - BUILDING INSPECTION (3) The Commonwcallh of Massachusclis Town of
// + Board of Building Regulations and Standards �w
Massachusetts State Building Code, 780 CMR, 7'"edition Building Dept
` Budding Permit Application To Construct. air. Renovate Or Demolish a S
1 I One- or riru-Puna Ot rNtng
This Sccuon FQk OR t Onl'
Building Permit Numbe
Signature: 3O/4 '
iu—,Iding—Commlssiomrllnsplwvforor Buddmgs Date
SECTION 1:SI INFORMATION
1.1 r pisrly Address: — 1.1 Assessors Map At Parcel Numbers
N M Number Parcel Number
I.1 a Is this an acce ted s rdt'!yes no W
IJ Zoning Information: 1.1 Propersy DltsseaStan$:
Zoning DistrictProposed Use Lot Area(sq 11) Frontage(t1)
1.S Building Setbecks(ft)
Front Yard Side Yards Rem Yard
Required Provided Required I Provided Regwred Provided
1.6 Water Supply:(M.G.I.c.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Public O Private O Cheek if vesO
SECTION 2: PROPERTY OWNERSHIP'ri'I Owner'yfR�Sprd•-/ �- / � Id- ( J\)V\r<v 5t
Name
A'Wnd Print) Address for Service:
-7$I--1 4 1-
Signature Telephone
SECTION l: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction O Existing Building O Owner-Occupied O Repair (s AltentioMs) O Addition O
Demolition O Accessory Bldg.O Number of Units_ Other O Specify:
Brief Description of Pro sed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item I I hnr and Materials
I. Building f I. Building Permit Fee: f Indicate how fee is determined:
O Standard Ciry/Town Application Fee
1 Electrical S O Total Project Cost'(Item 6)it multiplier x
J Plumbing S 2. Other Fed: f
4. Mechanical (HVAC) S List:
J Mechanical (Fire S Total All Fees: f
Surinres,tionj
Check No. _Check Amount: Cash Amount:-
6 Total Project Cost. S 2006 0 Pad to Full O Outsundmg Balance Due:
SECTION 3: CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor(CSL)
License .Number Esprrition Diu
Nyae ul CSL Ilylder Li+t(SL Type(rY twluw)
a
AJkess Ttor I Description
U I Unrestricted(up to 33,000 Cu. Ft.
R I Restricted IA2 Family Duelling
Signature
M Masonry Only
RC Residential Roofin Covering
Telephone Residential Residential Window and Sithrill
SF I Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signatara Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. I33.1 I3C(6))
Workers Compensation Insurance affidavit must be completed and submined with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed AMdavit Attached? Yes.......... O No........... O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I. M-1 ael e. �i 1 Z C�'e�,L 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 name of Owner Date
! SECTION/7b':OWNEW OR AUTHORIZED AGENT DECLARATION
I, M:CK n I,e .TZ.(_9 r�C / as Owner or Authorized Agent hereby declam
I
the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behal
l I
Signature of Owner or AinNorizedAgena Date
St ned under the osins and penalties ofperjury)
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&M have access to the arbitration
program or guaranty fund under M.G.L. c. 1 a2A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110 R6 and 110 R!,respectively.
2. When substantial work is planned•provide the information below:
Total floors area(Sq. Ft.) (including garage• finished basemenNanics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Vumber of bedrooms
Number of bathrooms Number of half.baths
Type of hearing system Number of decks/ porches
Type of cooling system Enclo.ed Open
1 "Tool Protect Square Fuoiage'•may he.uh,muted for"Total Project Cost"
CITY OF SMY-NI
PUBLIC PROPERTY
DEPARTMENT
K1t rYr�l1'.r. 130W.DUNGWOsMEW0 SMAK%1AJ&A0&S9M01"
r1L 916715.9s" • FAX 97L7.60.9W
HOMEOWNER LICENSE EXEMPTION
Plan" "t
Date i l 3u o
Job Location Q JN��Ct �t
Home Ownett Address Y
Home Owner Telephone ( �v3
Present Mailing Address
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or less and to allow such homeowner to engage an individual for
hire who does not possess a license.provided that the owner sets L supervisor.
DEFINITION OF HOMEOWNER
pawn(s) who owns a passel of land on which he/she resides or intends to reside.on
which then 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 bye-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 coda
CITY OF SALEM
PUBLIC PROPRERTY
is 4J' DEPARTMENT
I,W XI tl I•NIM,'•II
12I)w.11111m;IiNl)rst:rT •SA P\1, Sf.Ni.\t 1
fE1:WS-143:9995 I'.t%:978'740.9846
1
r Construction Debris Disposal Af idavit
(required fur all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # . _ is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111. 5 150A.
The debris will be transported by:
C it- IJ oar\ ri
(name of hauler)
The debris will be disposed of in
(name ut aci ity)
(address of tacillly)
signature of permit applicant
1t / 3yla
date
.Irh,,.�ll due