23 PARK ST - BUILDING INSPECTION (2) I _ - --- I'he Commonwealth of Massachuscus
11,E i; {� hoard Of Building Regulations and Standards C ' Y OF
I Massachtuetts State Building Code, 780 CNfR ALEM
IUJJ1 L�,.. R isdd ILrr_'ll//
Building Permit Application To Construct. Repair. Renovate Or De lolish
One-or Two-FaindY Du e/liu,\+
This Section For Official Use Onl
Building Permit Number L h Date Ap lie • n ] 7
Bull
Marc)
G-� 1 z
wlJing Olticial(Print mne) . ignaturc Date
SECTION I:SITE INFOICNIATION
1.1 f
�ro crag Address: 1.2 Assessors Map& Parcel Numbers
� � !'g/l=ail A u 0
I.1a Is this an acre ted street?yes no ` Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Znning District Proposed U e Lot Area(sq ll) Fmnlage(III
1.5 Building Setbacks(R)
Front Yard Side Yams Rcar Yard
Required Provided Requircd I Provided Required I Provided
1.6 Water Supply:(MA.I.c.ao,§Sa) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposals)
Check il' es❑ P stars ❑
SECTION2: PROPERTY OWNERSHIPI
2.1 wrier of Rec d•
,7 Font ��� .�',4/F/j1 A9,f O/97 0
le(ant) r - ty,St� aria ZIP'
�. ,Wt et
N'u.ni trcct relephune Finail Address
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupid ❑ Repairs(s e ) ❑ Alteration(s) ❑ Addition ❑
Demulition ❑ Accessory Bldg.❑ Numberof Units_ Other ❑ Speciry:
Dri Descri riot of Proposed 1Vorks: co
DER
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and.\Ialerials) Omcial Use Only
I. Building S /g d00. o a 1. Building Permit Fee:f Indicate how fee is determined:
2. Electrical S 000 ._ p o ❑Standard City/To%vn Application Fee
❑Total Project Cost (Item 6)x multiplier x
1. Plumhln9 S d , c o ] P
00 Other Fees; S �\
J. \1echanieal III\.\(') 5 LisC_ --- -- 1��/ /)
Q/ 3 \leeh:mieal (Fire S -- -_ - - .. ___.—
tiu,+ressionl Total .\II Fees: S
t'hcxk Vo. ('heek Amount: l',lih \maunl:
o. Total Project Cns1: 5 ---- ----
a00_ o u ❑ Paid in Full ❑Outstanding Ilalmtce Due:
al
t ,
SECTIONS: CONS'I-RIIC'riONSERVICTS
5.1 C'onstruction Supenisur License(('Si,)
I icensc Numhcr "-' _... I virainu Dae
N:une ol'l'Sl. l balder
1 i.al l'SI.
_ I Description
No. mid "vP''
U MAppliances
rccl I ILtilJin�s li In 15,Oot cu. IL121'amil DmellinRC' rinSF rning AppliancesI
Tek hone Finail address D Demolition
5.2 Registered Ilume Improvement Contractor(HIC)
IIIC Registration Number F\pirntion Dale
I IIC C'nmpin) Name or I IIC Itcgistru t Name
No.and Street Email address
Ci !Town,State,ZIP rele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152.J 2SC(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 ..........Cl No...........Cl
SECTION 7s: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING 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 Utmer's Name(Elcclrunic Signature) Date
SECTION 7b:OWNEW 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 it his application t ue and accurate to the best of my knowledge and understanding.
I'ri'i U sncr's or.\uthorireJ gau's None Il.lecuunaa Slgnaturul Dale
NOTES:
1. ,\n Owner who obtains a building permit to do his.her own work,or an owner who hires an unregistered contractor
(not registered in the Hume Improvement Contractor(HIC) Program),will rro have access to the arbitration
program or guaranty fund under`,I.G.L.c. 142A.Other important information on the HIC Program can be found at
tt ts,s m.r.. p AA Information on the Construction Supervisor License can be found at nm,c:;r's Jib.
2. \\'hen substantial\wrk is planned, provide the infonmatiun below:
rotas flour area isq. R.) _ __.._(including garage, finished bascmentattics,decks or porch)
Gros living area isq. 11.1 --- Habitable room count
Ntanber of fireplaces .... _ Number ol'hedrooms
Nunther ol'hathrooms \'umber of halth;ulls
I's pe otheating s stem Number ofJccks, pordtcs
I v lie od 000hng s\stelll I'ncloscJ ".
(!pert
i
t, Ibtal Project Square Poolage"flap he sub,titmcd fir"fotol 1'roject Cost"
CITY OF SALE.M
PUBLIC PROPERTY
DEPARnj. LENT
Klf�{11I.u.rvti.
MA1I'Oe t1/7�oYMGTaM?I111sT�Snuy VwfM011ftTTfOlf'0
17r.f'F7�SfSff�F.ut f'L7169ay
HOMEOWNER LICENSE EXE.Mffj0j*1
P1saw friar
Date d � a
rob Location W 2 Agk r4 1411-- .r a, u O/ 0
HomeOwuaAddress ZT O.ag/�jr./ Ao ic/70
Home Owner Telephone g 8'• k7 c
Present Mailing Address ZI /��7 O
The current exemption of'Womeownew"was extended to include owner-occupied
dwellings of two Units or less and to allow such homeown as to engage an individual for
hire who,does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Pason(s) who owns a parcel of land on which he/she resides or intends to raider on
which there is, or is intended to be6 a one or two family dweWng, 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
Imneowne"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 otha 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 requir cuts.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING rNSPECTOR
See other side for state code
i
CITY OF S,U-&N[, Akss,kcFjL:SETTS
BCQDLYG DEP.Ait-m r
110 W.1SH6VGTON STREBT, 340 FLOOR
ItL (978) 745.9595
K)J®ER1 RY OMWOLL F.ILx(978) 740.9846
.tiUYOII NO&LU ST•PMUS
DIRECTOR OPPLBLICPROPER7Y/9V DLVGCO.%O,jSS,ONEX
Construction Debris Disposal Atfidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section I I I.J
Debris, and the provisions of MGL c 40, S 54;
Building Permit g is issued with the condition that the debris resulting from
this work shell be disposed of in a properly licensed waste disposal facility as defined by MGL c
I I I, S I JOA.
The
/deebriss_will be transported by:
—1LL_LLV %P/I 7 .
(n4 me of hauler)
The debris will be disposed of in :
B7name ar r��dn I .�_
1dWell d�
f+udra r or r�odny)
v`. '
rynaNreofpc ifipphunt