55 PERKINS ST - BUILDING INSPECTION (2) --- I'lie Conunonweallh of MassochuseBs
N�Ili I 1: , Board of Building Regulations and Standards CI IN OF
(fY \I s EM SAL
1L Messachuselts State Building Code, 790 C'MR
J
ri.,ei/.1Gn•_'ill/
Building Permit Application To ConslrtlCt. Repair. Renovate Or Demolish
One- or rive)-Family Dn ellinkr
This Section For Official Use Only
Building Permit Number: ate Applied: _
q n
Building Official(Print Marc) Signature Dale
SECTION I: SITE INFORNIATIO
I.Tope y Address/ 1.2 Assessors Map& Parcel Numbers
T GQ /G / 1--t S Sj
I.la Is this an aces ted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions.
Zoning District Propowd Uwe Lot Area IN 11) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required I'mvidcd Required Provided Reyuind Provided
1.6 Water Supply:IM.G.I.c. 40,§54) o Flood Zone Information: 1.8 Sewage Disposal System:
Public Private❑ Zone: _ Outside Flood Zone?
Check it' vs❑ Municipal❑ On site disposal system ❑
SECTION I., PROPERTY OWNERSHIP'
2.1 Ownert of Record:
Mane(Print) City.State.ZIP
SS— (Pe -rs S � ��-7YS=[�oYY CG6vcc L Na C��
Nu.and Stmet Telephune Fmuil Address
SECTION J: DESCRIPTION OF PROPOSED WORKS(cheek all that apply)
New Construction ❑ Existing Buiidin Owner-Occupied Repairs(s)3C Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ I Number of Units_ Other ❑ Specily:
Brief Description of Proposed Work*:
�� yfi
SECTION q: ESTIMATED CONSTRUCTION COSTS
hem Estimated Costs: Ofllclal Use Only
(Labur and ..%lateriab)
I. Building S I. Building Permit Fee: f Indicate how fee is determined:
2. Electrical S ❑Standard CityrTutsn Application Fee
❑Total Project C-ostr i Item 6)x multiplier
7. I'lumhing S v, Other Fees: S -- —
J. Mcch.ulic.d 1I1\.\t•) 5 Lisc.- -'---
�u++cession) Toti All Fces: S
('hock No. ('heck Amount: _ l',uh �\mounc
I, Total Project Cast: S 0 Paid in Full 0 Outstanding 11.11;ulce Doc:
SE("P ION S: CONS I-RUcTIONSF.RVI('F.S
5.1 ('onstructimt Supen'isor License(C'SL)
I icense Number P\piruli�al Dole
N:une 01'01. I Ioklcr
__ _ - ----_ _.-----_—'--- 'Type Dcscriplion
No, and Street --_------ '—"-'- —
U (Inres!ricicd I llui Win 11 a to 35,II00 0 It.I
R Rearicled LC?F.nnd Doellin
SI Masan
RC Raclin C'overin
W'S W'indosv and Sidin
SF Solid Fuel Burning %ppliances ICI
I Insulation
I'cle !tune Finai!adJrcss D Demolition
4,2 Registered Ilome Improvement Contractor(HIC)
IIIC Itegistrltion Numl+er F%pintlion Date
I IIC C'ontpin) Name or I IIC Registrant Name
No. and Street Email address
Ci /Town, State ZIP refs hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152.1 23C(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 .......... O No...........O
SECTION 7s: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as0110a. r of the subject property, hereby authorize
o ac behalf,in all matters relative to work authorized by this building permit application.
Print Ow •r's Nan (Electra arc Date
SECTION 7b:OWNER' 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 Uttncr'.+or:\uthorircJ,\gcnl's Nuntc 1 Eleelnntic.Signature) Dale
N(J'f ES:
70%%titrr who obtains a building permit to do his.her own work,or an owner who hiresan unregistered cuntractur
tered in the Hume Improventevtl Contractor IHIC) Program),will rra have access to the arbitration
ur guaranty fund underM.G.L.c. (4'_A. Other important information on the HIC Program can be found at
. 't ", I Information an the Construction Supervisor License can be found atbstantial work is pivmed, provide the information below•.ea 1 sy. 11.1 _ ____.._I including garage, lmishad basement attics,decks or porch)
Gross living area[sq. 11.1 --_. _ Habitable room count _ ..
Nunlberul lirepbces -... . _-.. . . Numberofhctlrooms
! Nuntherol'hmhrounls
I)lie afheati»gsyslent . . . Vunlherofdecks- porches
I'ncloscJ t)pen
� I 1 pe Ut CJPllllg i\SI¢I11 '
1. "fatal Proj"I Stivare Footagc"may be substituted IUr 4focal Project Cost-
t
CITY OF SMY.1I
PUBLIC PROPERTY
DEPARTMENT
KJlatala♦l��...'.w .
MAVM ib WADW ."muss•&MAK VwaeowSKrnOtf-e
to$-sa.s-s»s•t=..s.9W40-9646
HOMEOWNER LICENSE EXEMIMON
plea" Fi I
Dam IZZ k2_
Job Lacadoe
Home Owner Address s- G' 4f u r 5:,-
Home Owner Telephone - --1 Ys-- vv y y
Present Mailing Address .S r , r--s Sr
The current exemption of-Homeowners"was extended to include owner-occupied
dwellings of two Units or lea and to allow such homeowner to engage an individual for
hire who,does not possess a license provided that the owner acts as supervisor.
DEFQdJTION OF HOMEOWNER
Penon(s) who owns a parcel of land on which halshe resides or intends to resider on
which there is, or is intended to ben a one or two family dw o ing, 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"asewnes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undenigned "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 req irem m
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF S.u.Ear, AUSACHUSETI'S
ditaOLVG 0EP.1ATtL\T
110 WA AKNGTON STRSST, 1'O FLOOA
M k973) 74S.9595
F,Vc(974 14&9844
'UJ[Bl_RLfiY DRLSCOLL
MAYO X motW ST.Pat"s
DIRUTOIl OP PL MIC PROP81<TY/BL:MDLYC CO.%L%IIS3fOV EX
Con9truction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Cade, 730 CMR section 1 I I.S Debris, and the provisions of MGL a 40, 3 54;
Building Permit M 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 XIGL c
I I [. S I JOA.
The debris will be transported by:
(n4me urhoular)
The debris will be disposed Orin :
a—s—, � C� r >r S
(name aY facdilYl
( Jdral aYAcdilY)
� mra u permit ipplwrnt