11 PARLEE ST - BUILDING INSPECTION k4-
_ 7 I hu Comnwnsvc;thh of��hu�;lihusclts _
s; Board of Building Regulations and SLutdards Cfl')' OF
') F"lussachuset S State Building Code. 780 C•hIR SALIi\1
Building Permit Application ro Construct, Repair, Renovate Or Demolish a
(Are-or riru-kanufr Du'dNin,\r
Phis Section For 011ieiul Use Onl
Building Permit Number: D ed; !
It��
Iluilding Onicial(1 ins Nmne) . igttalurc Rule
SECTION I:SITE INFORAIATIO
1.1 Pr��erty dress . 1.2 Assessors Ala Parcel Number _
L la Is this an acce ted street?),es no Nlap Nunthvr Parcel Norther
1.3 Zoning Information: 1.4 Property Dimensions:
Luring Dislricl Fn puseJ llse Los Amu(sq tll Friuli ise ill)
1.5 Building Setbacks(B)
From Yard Side Yams Rear Yard a
Required 1'ruvidcd Required Provided Required Provided
1.6 Witter Supply:(M.G.I.e. 40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Line: _ Outside Flood Lone?
Check if yef❑ Municipal❑ On fit*disposal s)stem ❑
SECTION2. PROPERTY OWNERSHIP'
2.1 Owners of Record.
N;une!Prins (uy.lsate•l.IP
Nu.ands tees rcicphone Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building O OWner-Occupied ❑ Repaln(s) ❑ Alterat(on(s) ❑ Addition O
Dentolilion ❑ Accessory Bldg.0 Number of Units_ Other ❑ .Spevq:
Brief Description of Proposed Work% 6, �
•
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Eslimated Costs:
I1.ahur and Materials) Official Use Only
I. Building S I. Building Permit Fee: S Indicate how tee is determined:
'. Flct;trical S ❑Standard CityTassn Application Fee
❑Tunl Pru ect Plunihiny Cost)I Item 6)x multiplier
S _ — x
1 1
.. Usher Fen: S-
J. \Icch.utic.d ill\ \(') S List:
\lech,wieal 'Fire '— -- ---- -..
':u..rmsmni rntal \II Fees: S—_---_—__— _. .._..
n 1-ulal Project Conk i Qd� C hecA \'u. (-haA :\nunuu: l',ieh \motim.
O P.tid in Full Cl Owsemding Ilal.uwe Due:
1�1a��fGKl.rl LT ( G Z �o U �
Sj:( I ION 5: ONS FRUCI-ION NERN'R II
5.1 (,011structio,, Sul)cnisuri.icellse ((SI-I
y\jiiralion Dole
NoIllet(SI iloitler
1341: Daicripiion
NO, 7111d street ti 11i,re., i.edilliddiii-sli
11 JoInot: x- -"I'll MwIlill
Cityi Tut,n,Stale,-Fill— M slamil
lic K,K,Ijn Co%crin
\4 S ix rijim, Lni Sidil
SF suli'd hucl llurning Applian"ll
I Insulation
1'ele hone
I:inail addressD
Danolition
4.2 Registered flume Improvement Contractor(IIIC)
FRIC collipaij) NrIljc
Fmail addricis
No, and Street
retephone
SECTION Ili 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 atYidavit will result in the denial of the issuance of the building permit.
Signed A Milavit Attached? yes .......... E3 No...........0
—':
----SECTION Fj� 51 1 .AUTHORIZATION TO BE CONIPLETEDNVHEN
OWNER'S AGENT OR CONTRACTOR
RACTOR APPLIES FOR BUILDING PERN.1IT
1, 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.
Data
i cn AGENT DECLARATION
crr-TJ1)N7h! OWNER 0—
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the inloirmatiun
contained in this application is true and accurate to the best or my knowledge and understanding.
P"
jig
NOTES:
\n 0\Iiner oho obtains a building permit to do his her own tsork.uran owner who hires an unregistered%wiltridur
(nut registered in the Huille 1111provenitnt Contractor(HIC) Progr3nill.%vill nu have have access to the arbitration
program ur guaranty fund wider\I.G L. c. 142.A.other impunant intormation on the HIC Program can be found at
I information on the Construction Supervisor License I be found at—%
lien substantial\kork is pl;illned, provide the infur rinndIuojni bcloa%vra:
ge. finished basement attics.decks or porch)
Total flour area , g g
flobimble I cutillt
\;tirilher tit hedrtwill'
liall'ti-111"
NtitnNrot hathroums Number ol dc,:ks porches
I pe Ill Ile.111119 j.%'Mr
i-or lotol ilrt-I 01,t
';quare 1:00I.We ' 11M.'t ('g 'uhslitti
CITY OF SM-E.M
PUBLIC PROPERTY
DEPART04NIENT
wvo 130 7UwrwGa.lman @lour wsnow mm os 9 V
I M rW+ssssl•v.&r.s.n+o1w
HOMEOWNER LICE.rSS EXE.NMIO4*f
i'1nN hart
Date
lob Location
Home Owner Address
Home OWW Telepboan 47IT. -- - _ -
Ptesed Mailing Addraw
ne current exemption of"Homeowners"was extended to include ownar-0ceupidd
dwellings of My Units or lean and to allows loch homeowners to engage an individual for
hire who.does not possess a licenssi provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
person(s) who owns a pneal of laud on which WSW reside or interWo to reside. on
which there i4 or is intended to be,a sae or two ramify 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 bit considered a homeowner. Such
"homeowrice shelf submit to the Building Official, on a form acceptable to the Building
Offleial, that hdshe 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 bylaws utd regulations.
The undersigned "homeowner"certifies that he/she understands the City of Salem
Building Oepartment minimum inspection procedures and requirements and that helshe
.vill comply with said procedures and requirements.
HOMEOWNERS SIGNATL'U
APPROVAL OF SUILDING LNS CTO
Sea other vda for state cods
Y
CITY OE 5.1LIr.�I, AUSACHUSETTS
9L'tLOL4G DEtjA-ntEVT
I_'0 WAS)INGTON STAFST, 1'O FtOCA
172L k973) 143.9591
KIMBER F RY OALSCOLL FAX(973) 740.984
NW10 t l OXWST.PMXA■
OIX=TCta Oir PC atic PROPEATY13CMnmG cmaiISSION ER
Construction Debris Disposal Affidavit
(required for sit demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CUR section I 11,S
Debris, and the provisions of,MCL o 40, S 54;
Building Permit At is issued with the condition that the debris resulting from
this work shall be disposed of in a property licensed waste disposal facility se deAncd by,�IGL c
111, S I30A.
The debris will be transported by:
s� t° r`�
(n.une of hauler)
The debris will be disposed of in :
(nrm.o-1�y) .---
I,ddreis orn.d„y)
" n�'uroolperm,� ,pphcinf
',ia