6 PEARL ST - BUILDING INSPECTION (2) 7 tl
The Commonwealth of Massachusetts
Board of Building Re lations and Standards Town of
17 Massachusetts State Buildi Code, 780 MR, 7ih edition Wilbraham
Building Dept
Building Permit Applicatio To C ns ruct, Repair, Renovate Or Demolish a 413-596-2800
O - r va- rni! welli g Ext 118
T ecticitJ For 0JficiaVWCnIy
Building Permit N mbet([ltV
Da ied: % -`/-e
Signature:
Buildin ommissio - s c rof Bui tugs Da
SECT IN 1: SIT SITIE INFORMAkIlioN
LI Prop eyjyeWAddress:T %aurnbALI
ssors p rc tubers
I.1 a Is this an accepted street?yes no Parcel
1.3 Zoning Information: .4 Pro e y mensi
Zoning District Proposed Use Lot Area(sq ft) 40age(ft)
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;EJ Private❑ Zone: _ Outside Flood Zone? Municipal)@ On site disposal system ❑
Check if yesW_
SECTION 2: PROPERTY OWNERSHIP'
2.1 wner of Record: n
Name(Print) Address for Service:
atur Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ TExisting Building❑ Owner-Occupied Repairs(s) ❑ 1 Alteration(,) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units PC Other 1�1,Specify:'ti IP t^rU�C
Brief Description of Proposed Work':Wo?ywtan /cnolC✓w. J:; P-
"d'7_(P Aa,"fbnxwti �(.Ot✓_� !?e,�-wets'Gl•"WOr/�C4 nn"r. Ll:-otn.c-.rfeGcl p re!/ia{e,.
�ZPWre 4 nyiieA 148,% lnut/- ��r Ftuw^L
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ aspr,- W 1. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical g ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ Q 2. Other Fees: $ �
4. Mechanical (HVAC) $ O List:
5. Mechanical (Fire
Suppression) $ U Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ (7- 00 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL-Holder Liu CSL Type(see below)
Type Description
Address U Unrestricted(up to 35,000 Co. FL)
R Restricted I&2 Family Dwelling
Signature M --MasonryOnly
_RC Residential Roofing C_everin
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signanue Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.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 COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 �+�-fx7�t? rw— P IL4 �' t---' as Owner of the subject property hereby
authorize to act on my behalf, in all matters
relative to work erti 'zed by this building permit application.
Si natureof Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
01
,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 Na
Signature of Owner or Authorized Agent Date
_Signed under the pains and penalties of perjuEZ2
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 not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A.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
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 SM ENI
PUBLIC PROPERTY
DEPART i ffiNT
K11dFlliY rvwvv
VwroS _ 130wASUNGTONSMAT•S.�� %L%s %CHLSK no1970
T EL 97.1-715-9s9S• F OL 978-740.964
` 4
HOMEOWNER LICENSE EXEMPTION
Please Print
Job Location
Home Owner Address
Home Owner Telephone Q-7 3
Present Mailing Address 'PL'-) (So-k ES3 Via,lEv-
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 who does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER `
Persons)who owns a parcel of land on which he/she resides or intends to reside, on
which them 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 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 SIGNATURE '
APPROVAL OF BUILDING INSPECTOR
See other side for state code
I
CITY OF SALEM
� A PUBLIC PROPRERTY
DEPARTMENT
i
Construction Debris Disposal Allidavit
(required for all demo Iit it)11 and rcnua:rtion work)
In accordance %%iti the sixth edition of the State Building Code, 780 CNIR section 1 1 1.5
Dcbris, and the provisions of N1GL c 40, S 54;
Building Permit ft is issued with the condition that the debris resulting from
this work shall he disposed of in a pruperly licensed waste disposal facility as defined by MGL c
III. S 150A.
The debris will be tr:m;ported by:
I name of hauled
i lie debris will be disposed of in
tnjina ul ta�ihty)
luddrei.ut lacilnYl ///-/
H L'IlalO a of pennrt applicant
date