23 PHELPS ST - BUILDING INSPECTION (3) The Commonwealth of MassachusettsSF'f CY€
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Board of Building Regulations and Standards SALF
Massachusetts State Building Code,780 CMR ' JUAe sf�d Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demoli L s+ A 11: 4
One-or Two-Family Dwelling
19
_ `T��Seetjon Fdr cial Ida .
I Budding PerIDlt,hhmr{ie�', I.Date Applied:
1 iitilding Official(Print Name) Signaaae
SECTION 1:STTE IiP ORtkTA 1IOl!1
61 i 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
2-5 Fl 4
1.1 a Is this an accepted street?yes_ no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District proposed Use Lot Area(sq R) Frontage(ft)
1.5 Building Setbacks(it)
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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yesO
SECTION 2: PROPERTYOWNFRSHIPr
2. Owner of Record: �' ti�1 E`Pn ,�l0
V ROgex- V37 �" ed
Name ) City,State,ZIP
23 FZ el�o5 IA • �l8-?4ti ,�4.o°f � &g
No.and Street Telephone Email Ad s
SECTION 3:DESCRIPTION OF PROPOSED WORK;(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': t r1 S^1-(xl.l Q'IDO V e C fO y.h�ea Po01 I f �i�]tJ1Z_
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials
1.Building $ 1• Building Permit Fce $ Indicate'how fee is determined:
U ❑Standard CityiTown Application Fee
o
2.Electrical $ 4 l�T' ❑Total Project Costs(Item 6)x muttipfier _ x
3.Plumbing $ O 2. Other Fees: $
4.Mechanical (HVAC) $ ll S List: _
5.Mechanical (Fire $ Og 7adt Q�1' Total All Fees:$
Su ression
Check No. Check Amount: Cash Amount'
6.Total Project Cost: $ Cam,'016 r ❑Paid in Full 0 Outstanding Balance Due: ..
1
S SECTION 5 CONTRUCTION SERVICES
51,Cohstruction Supervisor License(CSL)
License Number Expiration Date
;Name ofCSI.Holdei.L t' 4�+
List CSL Type(see below)
No.and Street T�p _Description
U I Unrestricted(Buildings up to 35,000 cu.ft.
R I Restricted 1&2 Family Dwelling
City/Town,State,ZIP M I Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
Y
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town, State ZIP Telephone
SECTION 6:WORKERS,COMPE!ISATION IIVSURANCE.AFFIDAVIT(M.G,I:a 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 7ai OWNER AUTAbid. A ONTO BE COMPLETED WHEN
OWNER'S NT OR C CT .R APPIIE$IFOR ING PERMIT
I,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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNFW 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.
7 & ER w T,F o Y lfio.,e k 0 201(o
Print Owner's or Authorized Agent's Name(Electronic Si ture) 0 Date
NOTES..
1. 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 can be found at
mm mmLgovloca Information on the Construction Supervisor License can be found at www.mass.eov/dos
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.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"
QTY OF SALEM, MASSACHUSE M
BUILDING DEPARTMENT
`. kttyld 120WASHNGTONS71REET,3PDFLOOR
TEL. (978)745-9595
KIA BERLEYDRISCOLL FAX(978)740-9846
MAYOR TrIOMAs ST.PIERRE
DIRECTOR OF PUBLICPROPERTY/BUILDING CD&WSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT.
Date"u�?_q� 120�tp
Job Location_,?, Pkp J��p g Sjj o 1 mA O 1 C1
Home Owner Addres MCI
Present Mailing Address 50jM?
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
APPROVAL OF BUILDING INSPECTOR
25-0320—
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25-0321 25-0297
2r-0295
2F�0294
25-03SS
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25-Oa24,
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25-0 27
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25-0325
25-0282
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25-0328 2r�OZB 250284
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