9 PEARL ST - BUILDING INSPECTION (2) i.
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6
'rhe Commonwealth of Massachusetts
9
� Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR 2N)V01b a J; r 20l
Building Permit Application To Construct, Repair, Renovate Or Demolish"a � (' 3
One-or Two-Family Dwelling
This Section For Olfcial Use Only
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Building Permit Number: Date pplied: a
19 (
Building Ottiicial(Print Name) - . Signature Date
SECTION It SITE INFORMATION'
1.1 PrP a dJ��ress: , 1.2 Assessors Dlap&Parcel Numbers
S
/l L la Is this an accepted street9 yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq tl) Frontage(11)
1.5 Building Setbacks
Front Yard Side Yams Rear Yard
RequircJ 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? Municipal❑ On site disposal system ❑
Public❑ Private❑ al Check If es❑ P po y
SECTION 2: PROPERTY OWNERSHIP,
2.1 O r'of Record
xI 1 n4?.K: f kit.
�me(Print) City,State,ZIP
_ , PeoI �+
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work-:
P
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building $ I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Costa(item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
i.Mechanical (lIV;\C) S List:
5. Uechanic:d (Fire S rotal All Fees:S
Su ressiun)
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S 12 ❑Paid in Full ❑Outstanding Balance Due:
\ 1"(�E.7dC(�� 4 �.�, �C�crit3s�p ttl2�
Ca& , V(p _ �� ��� �%
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Nance of CSL Holder List CSL'rype(see below)
No.and Sued
Type - - - Description
"
U Unrcstricted�(Buildings lip to 35,000 w.Il.
R Restricted 1&2 Family Dwelling
City/fawn,Stale,"LIP M Masonry
RC Rooting 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
IIIC Company Name or HIC Registrant Name
No.and Street Email address
Cityrrown,Slate ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L:c. I Z.¢ 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 Istuance of the building permit.
Signed Affidavit Attached? Yes ..........❑ No........... 13
SECTION 7a:OWNER AUTHORIZATION:TO BE.COMPLETED.W HEN:
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
J,U a rlV\ 1-IY1&rf5 I ► - 30 - l
Print Owner's Name(Electronic 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 in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 no have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program can be found at
m l %eww lss eov'oca Information on the Construction Supervisor License can be found at www.mass.,oVAlvs
2. When substantial work is planned,provide the information below:
\ 'total floor area(sq. ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. ftJ Habitable room count
y Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
type of heating system Number of decks/porches
rypeofcoolingsystem Enclosed Open
J. `Total Project Square Footage"may be substituted for"'fold Project Cost"
QTY OF SALEM, MMSAMUSE TTS
( 1 > BUILDING E
DEPARTK N17
120WASHINGTONSTREET,3"DFLOOR
TEL. (978)745-9595
KIMBERLEYDRISCOLL FAX(978)740-9846
MAYOR THomm ST.RERRE
DIRECTOR OF PUBLICPROPERTY/BUILDING COWSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Dated —3 — ( I . .
Job Location
Home Owner Address Sao, ft QQN M 4 Q
Present Mailing Address / b_YYIt\flvl b ( 17
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
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 understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE 1)�)QV)U �I nq r-e
APPROVAL OF BUILDING INSPECTOR r
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CTya ALF.K MASSAa§MT
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Construction Debris 01S*v0S ►1AfffldmWt
(required forall demolition andrenovation work)•
In occurdamce wo d►e"edWon of the State Bu ift Code. 780 a% SeCdM 111.E Deft,
and dK provisions of MGL co,554; ftdWW Pennitlt is issued with the
con�tlori that the debris frmn this wrorkshsft be
•
disposed ofina
waste de fad as licensed
P� hY defined
by MGL c 11 S .1, 15QA•
The debris will be transported by:
4P-/ / l
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
a V- S
Signature of applicant
6 —
Date