10 PEARL ST - BUILDING INSPECTION (3) The Comnwmcc:dth of N1assachuSCUS
�\a Board of BuildingRCgulatlUn.S and StandardS I'()R
Mt'NI( II'.Al.l l l
N4ussaclutsctts State Building Code. 7Sl) ('iv1K. 7" edition
„r Building Permit Appliauion To Construct. Repair. Renovate Or Demolish a
One- or Tu o-1-ti il, D,rrllin,t L _uoN
II I^y1 This Se(tion Foy Official Use Only
Building Permit Nun er: ate Applied: /O -- -----
signatnre:
f3 it n onunncu",ed Insl,ceSE(- T Iuldi�ics SITE INFORNIA'FION --_
1.1 Property A dress: 1.2 Assessors Map,& Parcel Numbers
I.la Is this an i repted ,[feet? yes— no ..Alap `unbar I':,rrrl Numhei
1.3 Zoning Information: 1.1 Property Dimensions:
4 U C)
Zoning Dietrict Proposed Use Lot Arco(sq IU Frontage (It)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear l:ud
! Required Provided Required Provided Regtuled Prodded
L6 Water Supply: (NI.G.L c. 40. §51) 1.7 Flood Zone Information: 1.8 Sewage Disposal SyStem:
Zone: _ Outside Flood Zone'. ,Municipal El Oil site disposal ¢)stein El
Public Private ❑ Check if yes❑
ill SECTION 2: PROPERTY OWNERSHIP'
2.�wnertofR core
N�u ^Printl Address for Set vice:
T ) � 4 )3 ne
iile
"telephone
apply)
SECTION 3: DESCRIPTION OF PROPOSED %V )RK' (cheek all that pl y)_
.. )
New C.ons[ruc[ion Existing Building ❑ Owner Occupied ❑ Repairs(s) ❑ AItei.,lion(s) ❑ Add iti nn ❑
Demolition ❑ I Accessory Bldg. Number of Units J Other Cl Specify.
Brief Descri�tiono-PfoposedWork : --
(fin c�_ J
SECTION 4: ESTINIATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Lahor :md Materials)
I. Building $ I. Building Permit Fee: $ Indicate how fee is dc[nnnu,ed:
❑ Standard City/Town Application Fee
2. Electrical ❑TOtal Project Cost' (Item 6) x multiplier�� x .
i
3. Plumbing S 2. Other Fees: S
4. Mechanical (FIVAC) S I List: --- '
i. Mechanictl (Fire 5 --
Sup rnsionl � total :\Il Fees: S
_ Check No. C"hecK .-Amount Amount
I) Oct Cost:
rotal Pro $
J ' � (�O � � ❑ Paid m Full ❑ Outsumdim_ Balance Uue:____—_J
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL) III
1_iccnse Number ILspir:unnt D:ua -
Na of C'SL- I IuIJs
Li,( CSL f\pc isec below)
\JJrr,> fv c Deseri llum
l.- 1.'nrcumtcd w� to ?S.t10U Cu. Pt.i .
R Resin,tcd &2 F:umh Ihellim_
Signature M M;uonn ()nIV
RC Rc,iJcnuul Ruollne l'us crina
I'clephon' \\J Rcadnuial \VinJo�� .inJ .1iJuic _
SF ResiJrnual .... Fuel liana ne A h.mce In.l.illalwn—
D ItellJcu ual Ucuadrt n l
5.2 Registered Home Improvement Contractor (IIIC)
1-IIC Company Name or 111C Registrant Nance Regisuatiun Number
Address —
E.vptratwn Date
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVI'C (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.
Sinned Affidavit Attached'? Yes .......... ❑ No ........._ ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, ner 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 �I l y a� / (A /y <6
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the ains and penalties ofper-jury)
NOTES:
I. An Owner who obtains a building permit to du his/her own work. or an owner who hires an unregisieied contractor
(not registered in the Hume Improvement Contractor (H10 Program), will not have access to the arbiu-:uion
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Progran ;md
Construction Supervisor Licensing (CSL) can he found in 780 CMR Regulations I 10-R6 and 110.R5- icspecticely"
' When ,ubsiannal work is planned, provide the mti i mation below:
Total floors area (Sq. Fi.i (including garage, finished base ment/anics, decks m pmdii
61os.s living area lSq. Ft.) Habitable moot Count
Number of fireplaces Number of bedroom,
Number of bathrooms Number of halt/ba ,
Fvpe of healing system Number of deck,/ porches _-- -__---.
Type of Cooling system Enclosed Open
3. "Total Project Square Fooage" may be substituted for "Petal Project Cost"
_J
CITY OF S UE.M
PUBLIC PROPERTY
DEPARTMENT
ouxcu
Vwroa 130 wAva«GTON 4r>xr.r• f SuEt{NwStK]rl:ShTR 01970
74i 978•74$4M• Fax:978-740-99"
HOMEOWNER LICENSE EXEIMMON
Please Print
Date
Job Location
Home Owner Address r I
Home Owner Telephone
Present Mailing Address
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
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 fora 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 requireme d-tharlic—/she
will comply with said procedures an rem
PY w P rnW
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SALEvi
ilf A--- PUBLIC PROPRERTY
• DEPARTMENT
:., ... t
\I .•...K Il. VI`.wSUIX�C:J��:R�ET � S.\t.
CFI
Construction Debris Disposal Affidavit
(required Cur all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, ISO CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit Ai _ _ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111. 5 150A.
The debris will be transported by:
_ua-d
(name of hauler)act,-"
I'Le . ,:bri`s will be disposed of in
1
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