33 NURSERY ST - BUILDING INSPECTION (3) 420 Ck 4 � 13,3
T The Commonwealth of MassachuY
Board of Building Regulations and-StsettsAW
CITY OF
Massachusetts State Building Code, 780 CMR SALEM
uu``11 �AA p 'L; Revised Mar 201I
Building Permit Application To Construct,Repair,ItUib l(lf.Hemolish a
One-or Two-Family Dwelling
t This Simon For bfficm Use Only"
n Building Permit Number-,. Date A 'ed:
`-Bmlding Ofliciai(Petit Dame) - %nature-
SECTION 1:SITE INFORMATION
1. rty Address: 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an acce ed street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) 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 Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTYOWNERSHIPr
2. ownerro{Record:
�e 4.� „^
C792 ,( �cc7cYG V `
Name( 1 City,State,ZIP
Sire
No.and Street Telephone _7 Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ I Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Bri Description of Proposed World:
r Y D r
a a 0 1 e
Per
SECTION 4:ESTIMA D CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:S Indicate how fee is determined;
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cosh(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees:
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
Su ression
/\ 6.Total Project Cost: $/b 41 000. 0 Check No. Check Amount: Cash Amount:
❑Paid in Full- 00 utstandm Balance Due: -
rn fA t T-D k-k, r) g l 2
SECTION 5: CONSTRUCTION SERV14M T
5.1 Construction Stipervisor-Liceuse(CSL)
' 1 .(7 ," License Number Expiration Date
Name of CSL Holder " ' u
List CSL Type(see below)
No.and Street -Type Description. .
U I Unrestricted(Buildings up to 35,000 ar.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town, State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION IMURANCE AFFIDAVIT(M.GJL c.152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMTLETED WHEN
OWNER'S AGENT OR CONTRACTOR APrLW,$FOR RUILDING PERMIT
I,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 Name(Electronic Signature) Date
SECTION 7b:.OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name belo ,I hereby attest under the pains and penalties of perjury that all of the information
contain in this applica is true and accurate[o the best of my knowledge and understanding.
riot Owner"
r Mihoiized 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 information on the HIC Program can be found at
mvnv.mass. oa v Information on the Construction Supervisor License can be found at www mass.gov/dus
2. When substantial work is planned,provide the information below:
Total floor area(sq.It.) (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"
r
N/F
STROUT
2't
50'
SHED N/F
YORK
LOT 40
5000±S. F.
_ o
0
N/F O PROPOSED 1 STORY ADDITION
RYAN r �
N/F
MCLAUGHLIN
,d
2 STORY
SINGLE FAMILY
#33 Y.
w
0
i STORY i T±
1
1
1
50'
33 NURSERY ST
PLAN COMPILED FROM VISUAL FIELD INSPECTION,SALEM GIS MAPPING,SALEM ACCESSORS DATABASE AND MORTGAGE
INSPECTION CERTIFICATE PREPARED BY REID LAND SURVEYORS DATED FEB 28,2001. PLAN DOES NOT INCLUDE -
LANDSCAPE,DRIVEWAYS,FENCES OR OTHER SITE FEATURES.
LAVOIE RESIDENCE SCALE 1" = 20'
33 NURSERY S}{T DATE SEPT 16, 2016
SALEhA IAACCAt'LVSETTS BOOK. 10237
y
Hill
EAST ELEVATION
PROPOSED 1 STORY ADDITION
0000 0
SOUTH ELEVATION
LAVOIE RESIDENCE SCALE 1" = 10'
33 NURSERY ST DATE SEPT 16, 2016
SALEM, MASSACHUSETTS
` CITY OF SALEM, MASSACI-IUSE TTS
` j BUILDING DEPARTMENT
120WASHNGTON STREET,3RDFLOOR
TEL. (978)745-9595
FAX(978)740-9846
KINMERLEY DRISCOLL
MAYOR THomAs STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRI T:
Date
Job Location ' ��k(�SPc/V S� L tA� p
Home Owner Address `' ' , rni P SLa ��C' ^� �/]��" \� /t�\j ( 7 D
Present Mailing Address�3 fV(CySt'ry 1 S�,I�' �µ t l
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
considerled.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 tha /she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR
07 YOFSALEA MASSAa-ASET7!
BULUMDEPAtMMa
120 WAst VXWS788ar,YDRAO tt
7kL(W8)74S9M.
PAX MIL9846
SII�ERiBYDRLSt�L
MAYCdt 7Yi�1�i1sST.P�10tF
DmscrcacFpuaucppxrmy/BumEmamenocHm
Construction Debris DisposaiAfdavit
(required for all demolition and,.renovation work)
In accordance with the sixth edition of the State Building code, 780 MR, SeCthn 111.S Debris,
and the provisions of MGL M, S 54; Building Permit it - is issued with the
condition that the debris resulting from this work shall be disposed of in a Properly licensed
waste deposit facility as defined by MGL c 111,S 150A.
The debris will bje� transported by.
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
—751
Signs re of ap iicant
Date