6 NURSERY ST - BUILDING INSPECTION (4) t �
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
9 Massachusetts State Building m Code, 780 CMR, 7 edition OF SALEM
Revised Janaury
Building Permit Application To Construct, Repair, Renovate Or Demolish a /. 20//8
^ One-or Two-Family Dwelling
This Section For Official Use Only
( I Building Permit Number: Date Applied: 15�q—
o
Signature: ✓ Vie
Building Commissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
I.1 -�rop��'�Y Address: 1.2 Assessors Map& Parcel Numbers
N�/ S..F-
I.la Is this an accepted treet?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(tl)
1.5 Building Setbacks(R)
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?Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
1 Owner ofRecgrd:
Kr. Uw�.nl� �I CLOte Tt ecc �
Name( ) Address for Service:
igrtaturc Telepgone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied-alRepairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work'-•
Cu- ^ �- r _,c-aee n ,�h014-k _C
n� ^.k.
�
- h� ofS 1zNtie J .motTl
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Olilclal Use Only
Labor and Materials
I. Building S i z, 60Cn, 1I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S
Su ression Total All Fees:S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S 1 Q p O ❑Paid in Full ❑Outstanding Balance Due:
F
�J h
l L�
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Dute
Name ol'CSL•I folder List CSL"type(see below)
.r pe Description
Address U Unrestricted(up to 35,000 Cu.Ft.
R Restricted IR2 Family Dwelling
Signature M MasonryOnl
RC Residential Routing Coverin
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or HIC Registrant N:une Registration Number
Address Expiration Date
Signature 'retephone
SECTION 6: 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 ..........O No...........O
SECTION 7a.OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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.
(f,-
-Signature of Owner Dote
SECTION 71b: OWNEW OR AUTHORIZED AGENT DECLARATION
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.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of 'u
NOTES:
I. 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 g(have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 1 IO.RS, respectively.
2 When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count j
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 SALEM
PUBLIC PROPRERTY
�• DEPARTMENT
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Trt;v%t-N}9i93 � F.\s:97�•N3'/XM
Construction Debris Disposal Affidavit
(required lur all demolition and rcnovatiun work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 11 l.5
Debris, and the provisions of MGL c 40. S 54;
Building Permit It is issued with the condition that the debris resulting from
this work shall he disposed of in properly licensed waste disposal facility as defined by MGL c
l l 1. S 150A.
The debris will be transported by:
one�.
i Mama or hauler)
The debris will be disposed or in :
(narrleul aci Ity .
I address of I':u ility)
+I�natwe of IlernliI.Ipplica
s ( � Gb
,late
CITY OF S.U.E.%vf
PUBLIC PROPERTY
DEPARTMENT
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TVL rs•71}9s99•FAX 9'6.7469670
HOMEOWNER LICENSE EXEMPTION
Flew hint
Date 6
JobLoeadon1-
Home Owner Address 1 .
Home Owner Telephone '7 -- kZ+ L
Present Mailing Addtae a Qn L A C
The current exemption of"Homeowners"was extended to include ownw-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 acto as supervisor.
DEFINMON 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 dwellin& 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
requirements.
HOMEOWNERS SiGNATI RE ► G�Q�L y� .aSZ�
,APPROVAL OF BUILDING LrSPECTOR
See other side for state code