76 PIERPONT ST - BUILDING INSPECTION The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
Mas5aC11U5e1t$Start Building Code, 780 CMR, 1'"edm°n ismobw
Building Dept
�{ tY Building Permit Application To Construct, Repair, Renovate Or Demolish a
One. or rtro-Fumr/t\Di%e1hng moms
V This Section For O,,Rcial Use Onlyl
v, Building Permit Number. I Dale lied:
Signature:
Budding Commissioner/Ins of Buddmgs Dne
SECTION I:S , E INFORMATION
I roperty Address:� 1 �1 1.2 Assessors Map& Parcel Numbers
1.1 a Is this an acce ted street'?yes ✓/ no 7 Map Number Parcel Number
I..S Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use La Area(sq III Frontage(it)
1.5 Building Setbacks(R)
Front Yard Side Yards Rem Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.a0,ISa) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public O Private O Zone: — Outside Flood Zone? Municipal O on site disposal system O
Check if vesO
SECTION 2: PROPERTY OWNERSHIP'
Own ' f Record: 76 /, QNT S�
A A SJN
Name F im Addrc or Service:
Signatur Telephone
ECTION J: DESCRIPTION OF PROPOSED WORKS(cheek all that apply)
New Construction O Existing Building O Owner-Occupied O 1 Repairs(s) O 1 Alteration($) O Addition O
Demolition O Accessory Bldg.O I.Y[iinsiser of Units_ I Other O Specify:
Brief Descri t'on of Proposed Work':
e A/c` o
SECTION♦: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: OlHclal Use Only
Item Labor and Materials
I. Building f 1. Building Permit Fee: f Indicate how fee is determined:
O Standard City/Town Application Fee
2 Electrical S O Total Project Cost'(Item 6)x multiplier x
Plumbing f 2. Other Fees: f
4. Mechanical (HVAC) f List:
s Mechanical (Fire S Total All Fees: S
Su ression
Check No. _Check Amount: Cash Amount:_
h Total Project Cost S �/OQO p paid m full 13 Outstanding Balance Due'
SECTIONS; CONSTRUCTION SERVICE
5.1 Licensed Construction Supersisor(CSL)
'' L.ccnw Numbef Esprrutwn Dote
N,yoe of CSL HylJer List CSL Type(see beluw)
a _-
To Description
Address
U Unrestricted(up to 33,000 Cu. Ft.
R Restricted Ih2 Family Dwellin
Signature .N I MasonryOnly
RC Residential Roofn Coverm
Telephone wS ResiJenttol Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I. c. 152.§ 2SC(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.......... 0 NO........... a
SECTION 7s: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.
Si narum of Ow Date
ZI SE N 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
1 �� ,as Owner or Authorized Agent hereby declare
that the s ents a information on the foregoing application are true and accurate,to the best of my knowledge and
Prin
� is iS o
ignat Owner ororized Agent Date
St tied u der the airs nalties ofu
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 Rg have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110 R6 and 110 RS,respectively.
2. When substantial work is planned,provide the information below:
Tool floors area(Sq. Ft.) (including garage. finished basement/artics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halfbaths
Type of heating system Number of decks/porches
Tv pe of cooling system Enclosed Open
1 "Total Project Square Footage" may he substituted for"Total Project Cost'
J� CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
u: MAVON tar' L 130 WADUPICTON h9aar 9 S L M VwsAORLstm 019'.e
M 9'674L9S"•F.uc 978.744964
HOMEOWNER LICENSE EXEMPTION
Plesse Mat
Dan
Job Location ' �� A11,5Z 5' -no 6 9 zd
Home 09vna Address
Home owner Telephone 7
plant Mailing Address G r ti
d �A
The current exemption of"Homeowners"was extended to include owneroccupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
hire who.does not posse" a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
person(s) who owns a parcel of Lod 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 stick 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 hdshe 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 insect' roc and requirements and that hdshe
.will comply with said procedures r Qtrem
HOMEOWNERS SIGNATL / d Z "
>,PPROVAL OF SUILDNG INSPECTO
See other side for state code
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.I\lit BI h.l !•MM '`I I
\I`.,,9r I_'0 U'.\iI IIVGI0?`151'NLL'T 0 5.\I 1'�t, ,Lt.N
1'r1:978-74 939$ • 1:.%x:978.7444846
Construction Debris Disposal At'tidavit
(reklplired I'or all demolition wid renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
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 he disposed of in a properly licensed waste disposal facility as defined by MGL c
I11. S 150A.
The debris will be transported by:
��
(name u I ul
The debris will be disposed of in
_.
Brame ul M,770
(address of lacitity)
v
signal )f permit applicant
date