68 PIERPONT ST - BUILDING INSPECTION (5) 1 --- I'lie C'onununtveuldt of blassachusclls
s 1� Bo,IrJ orBuilJing Rcgulatiuns ;mJ Standards ( I I') OF
( t?L ... Massachusetts Slats Building Cl 780('hIR �•\LE.\I
Building Permit %pplicatiotl TO Construct. Repair, Rcnovaro Or Demolish u Ruri.a / I ttr:u//
Una-ur riru-Pitntdl' Utrrl(in.v
This Section For 011i I Usc Onl
Building Permit Number: 9 to Ap led:
IAiilJiny Oliiciul(Prinl N;unc)
SECTION i; SITE NF A 'TION
L I Propert AJJrn • L A s rs Slap S Parcel Numbers
I.la Is this an acre tad street? es no Purcell Nt mhcr
I.J Zoning Inror,notlont Property Dimensions,
Luniny District I'ropascJ ll—�--_ Let Arco(sy III
1.5 Bullding Setbacks(R) Frontage Itl)
From Yard Side Yards Required Front
Reyuircd ProvidedReyuin.•d Rear Yard Provided
1.6 Water Supply.IM.G.1.e. 40, §54) 1.7 Flood Zone Information, 1.8 Sewage Disposal System,
I'll O Ill ace O Zone: _ Outside Flood Zone?
Check if csO Municipal O On site disposal n).aum ❑
2.1 OwnertALReeordt
SECTION1. PROPERTY OWNERSHIP'
T
IZi�,'^e ✓x s �� do d � A�g. 019,E o
N,unv 11 nif� / L ul,Salto,/.IP
554
Nu..mJ Stn'ct felephune
Email Address
SECTION J, DESCRIPTION OF PROPOSED WORKS(cheek all that apply)
New Construction❑ Existing Building❑ Owner•Occupiill ❑ R ill: 1(s1 O Aherotlonls) O Addition ❑Demolition ❑ Accessory Bldg.❑ Nun,bercrUnits
Brief Description or Proposed Work': Other O .Spceity:
rr
76l - �
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Itrns Estimated Costs:
I l.abur and.\laterials) OMclal Use Only
I. Building S I. Building Permit Fee: S Indicate huw fee is determined:
! _2. FIearical S ❑Standard City:Tusrn Application Fee
I t I'huuhing S ❑Tutal Project C•osl'(lten,6)a multiplier .e
'. Other Fees;
a. \Icdt.mie.d ill\ \('1 S List:
Ve�h.uur.d II'ire
Sit''f0S1klll I S r,rut \II tees: S -
1'ural I'rnject Cast i / ('has{. \u. _. _( hccA .\nnnult: l'.i,h \mownt:
U/��� ❑P.iiJ m Full ❑Oatstauding 11.11.mce I)uu:
Sr.('I ION 4: (INS I'RI'C MINSF RN R 1".5
liull Supervisor License((St.)
.1.1 ('onslruc lic
t01. I- Pig I'"
. 1'
mij mrckt
slaw.
RC K,I,din ,%vrin
%S whillitm Aid Sidii
I
SF—
sulij I:U9I Mulling'llpillialiccl
I Inadution
'D
I
hone
Dmnoliliun
a Improvement Contractor(111C) IIIC.%.2 Registered lion DA9
llIC C,Illlpjll) %lille 1q,IIIC lugotrunt Na111e
Email addMis
0. Aid Street
lity/Towli State ZIP rcle h in* 153.1 25C(6))
SECTION 6sWORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.
Work" Compensation Insurance affidavit must be completed and submitted with this aPPiIc9d0 . Failure to provide
this alYIdavit will result in the denial of the Issuance of the building Permit-
yes ..........Cl NO...........Q
Signed Affidavit Attached? AUTHORIZATION TO BE COMPLETED WHEN
SECTION 7otoWNERAUTH R BUILDING PERMIT
OWNER'S AGENT OR CONTRACTOR APPLIES FO
1, as Owner of the subject property,hereby authorize
10 act on my behalf.In All matters relative to work authorized by this building permit 2PPIlc2tiOn'
Dod
prillt U%vllcr,s Nariler(Mctntnic Signature)
AUTHORIZED AGENT DECLARATION
SECTION 7b-ONVNER' OR AUT
der the pains and penalties or perjury that all of the iniormatitin
By ene,,,n,,? noire below,) her attest under
contained it
_ 23 applil�atian is Ir'T and accurate to the best or my knowledge and understanding.
Duw
Print lla �j,,r.Nullulr,4411 %6 Narist
ner\vho hiresan unrcgistcredcuntractur
it to
27building P111011 to do;is.htr o\vn %%ork.ur an
An 0,ker N%hki kiblait's 1,,IprQvcIIlttIt Culittwor(HIC) Program).will!U) have access 10 the arbitration
I tut registered in the Ht lotion on the HIC Prograin can be found at
prograill ur guaGIIII) Ilulld under M.G.L.C. 1other iiiiporiant inforn can be found at
h C m1ruclIon
b=s Jocks
Or on e 0 upe M far
Informationall theCkinstruction Super%isarI_ik:tnse
h t n b,10%
_0 'A 13 ell 0 0 v led "W"t=tlls. J`:,�
lien subitantial Lurk s phoned. pro'kidd the i Ilcirlim.tion bclo%v: j"Its or por0i)
,I
11cludillil g�r,'t 1111 IS
;I ,ge, Ililished bascinclit
I IS P 'I
it
rota) flour area I ii.l. ruulll cOu'll
u
e I"I r cd rl ...'I,
Groii li%mg area 114. %imber kif hi:d.ruoills
of half K11114
hcr ofti.11hroollill
\toin I TreatingiTreating01wo
I I,Q
otal 1'r,,jckt 01it"
CITY OF SAL.EM, MxsSACHUSETTS
BuiLDLNG DEPAR-1-M&NT
120 WASHNGTON STREET, 3"o FLOOR
a TEL (978) 745-9595
Y
FAX(978) 740-9846
f<I\CBERLEY DRISCOLL
,Nf iYOR THomks ST.PIERAE
DIRECTOR OF PL13LIC PROPERTY/BUMDDJG CONL\IISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section I 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # 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
1 l 1, S 150A.
The debris will be transported by:
(name ol'hauler)
The debris will be disposed of in
-- (name of facility)
(address of t'acility)
sig -cure of permit applicant
date
lobriSal;:J.k
CITY OF Sm-oft
PUBLIC PROPERTY
DEPARTOMENT
[1�W4sY OtOI'a'
VwrOe I b'rAYW6Tb1 tnesr•luar4 VwSAollsen7 0N'0
M.f'.L71}9Sff t+.ut 971-71496e
HOMEOWNER LICENSE EXEMMON
Pfease Frf>tt
Date
Job Loeadas —
Home Owner Address
Home Owner Telephone
Premot Mauling Address
The current exemption oft"Homeowners"was extended to include ownar-occupied
dwellings of two Units or fees and to allow such homeowners to engage an individual for
hire who.does not possess a Icensa',provided that the owner sets as supervisor.
DEFINITION OF HOMEOWNER
Peraoo(s) who owns a parcel of land on which befshe resides or intends to reside. on
which then 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 but considered a homeowner. Such
"flaneowner'shall submit to the Building Omcial,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 bylaws 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 requir ens.
HOMEOWNERS SIGNATURE '
.APPROVAL OF BUILDING INSPECTOR
See other side for state code