2 PLANTERS ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Cute, 780 C'MR, 7'edition OF SALF.M
Rrvisrr/Jmnnrry
Building Permit Application To Construct, Repair, Renovate Or Demolish a /. (N)6r
One-or Two-Family Dwelling
This Section For Official Use Only
06 Building Permit No her: - Date Applied: 't
Signature: " `-�''j`o r O'-
J� Building{Cummissioner/1 spates of Buildings Date
(vl SECTION 1:SITE INFORMATION
1.1 Propetft Address: 1.2 Assessors Map B Parcel Numbers
Ir
L la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Properly Dimensions:
Zoning{District Proposed Use La Area(sq 11) Fronlage(It)
1.3 Building Setbacks(R)
Front Yard I 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:
Public O Private O Zone: _ Outside Flood Zone? Municipafl<On site disposal system ❑
Check if yesO
,Q�' SECTION II: PROPERTY OWNERSHIP' L
of Rec pvti /1r
Nome IPrinq Address far Service:
at�ure — Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(check aB that apply)
New Construction❑ Existing Building O Owner-OccupiedQ�. Repairs(s)X Alteration(s) ❑ Addition ❑
D
emolition ❑ Accessory Bldg.O Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work : Ate -,/
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 011lclal Use Onl
Labor and Materials y
Q 1. Building S / (JQ I. building Permit Fee:f Indicate how fee is determined:
O Standard City/Town Application Fee
_. Electrical S ❑Total Project Cost(Item 6)x multiplier x
). Plumbing S 2. Other Fees: f
4. Mechanical (IIVAC) S List:��V
5. Mechanical (Fire S
Suppression) Total All Fees:f
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S O Paid in Full 13 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
(rLicensedConstruction Supervisor CSL)
Lice n NuIm Inbres er tric ted u to lJaSp.0im00l iuCnu.I yF
att
e
der
st LiCSL Type(seebelow)
f Ikscri on
ss
,ddmss
UR Restricted Id2 Family D%elln
SignatureM
masonry Only
RC Residential Raclin C'overin
1'dephrme WS Residential Window and Sidin
SF Residernial Solid Fuel Burning Appliance Insiallaliun
D Residential Demolition
S.2 Registered Horne Improvement Contractor(HIC)
I IIC Cumpmy Name or IIIC Registrant Name
Registration Number
Address Expiration Date
Signature 'telephone
SECTION C WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C. 1S2.f 2SC(6))
Workers Compensation Insurance atTtdavit 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...........0
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relad work authorized by this building permit application.
7behalE
net Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
ements and information on the foregoing application are We and accurate,to the best of my knowledge and
rn
Signature of Owner or Authorized Agent [Yale
7nn
the ains and (ties of 'u
NOTES:
er who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor
stered in the Home Improvement Contractor(HIC)Program),will Oyj have access to the arbitration
or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
tion Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 10.116 and I IO.RS,respectively.
bstantial work is planned,provide the information below:
rea(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 half7baths
Type of healing system Number of decks/porches
Type of cooling system Enclosed Open
). "Total Project Square Footage"may he substituted for"Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
J 111L FI h.Y I-KN 1111 I.
\1 120 w.\i11IVG'1'0.NSrlt@GT • S.\I r\1. Si.\iiA1:111 -ii I"li jl`I
Fri:1/78.74 9595 11'AX:978-740-9846
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 111.5
Debris, and.the provisions.ot 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
111, S 150A.
The debris will be transported by:
(name of hauler) -
The debris will be disposed of in
&-y yf lrcc
(name 01 facl ityl )
(address of facility)
signature xnnit applicant
P a io
date
dchri u(I Luc
1
.
CITY OF S.U.E*vi
PUBLIC PROPERTY
DEPARTMENT
�. . L
wroe t 3e w swan•LUAK ywaeotisM 011'e
ttL 9 8.7U•7sss•r•..L rS.74&960
HOMEOWNER LICENSE EXEMPTION
Please "I
Dam S
Job Lacaacs
Home Owner Addreaa l s
Home Own m Telephone � T —6 ?el
Present Mailing Address la _- 11'A alg7U
The currant exemption of"Homeowners"was extended to Made owner-occupied
dwellings of two Units or lean and to allow such homeowners to engage an individual for
hire who,does not possess a licens%provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Person(s) who owns a pastel 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
stnscturm 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
BuildingCode and other applicable by-laws and regulations.
aPp Y-
The undersigned "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 irements.
HOMEOWNERS SIGNATI,'RE
,APPROVAL OF BUILDING DiSPECTOR
See other side for state code