7 PLANTERS ST - BUILDING FOUNDATION y
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The Commonwealth ofMassachusetts)NSPECTie a"tL SE WICWY OF
Board'of Building Regulations and Standards SALEM
I Massachusetts State Building Code, 780 CIVII7RIISS ���� e �,l.ilur 2011
Building Permit Application To Construct, Repair, RenovafeL7r TTem� h d ' �xU
_ 11 One-or Two-Family Dwelling
(v This Section For Official Use Only
OBuilding Permit Number: Date Applied:
L Building Otliciol(Print N:une). ' Signature, . - Date
SECTION 1:SITE INFORtNIATION
1.1 Property Add ess: 1.2 Assessors Map&Parcel Numbers
I�fiwv F�w.S 36
1.1 a Is his an acce ted street?yes_ no Map Number Parcel Number
1.3 Zoning Information:
/G 1.4 Property Dimensions: 7O
Mt
"zoning District Proposed Use Lot Area(sy tt) Frontage(It)
1.5 Building Setbacks(R)
Front Yard Side Yams Rear Yard
Required Provided Required Provided Required Provided
1.6 Water pply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Du posal System:
Zone: Outside Flood Zgafl Municipal tH On site disposal system ❑
Public Private❑ Check If yesfir
SECTION 2: PROPERTY OWNERSHIP"
2.1 ownertoMW.$&t Det►..IopMt+[[ f�+�ru�J, MA-
r0me(PrinNYt)' City,State,ZIP
p-o. 3� z�og 47Fr adn
No.mid Street Telephone Email Addrem
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction Existing Building❑ Owner-Occupied ❑ Repairs(.) ❑ 1 Altemtion(s) ❑ Addition ❑
Demolition - ❑ A I Other Cl Specify:
Brief Description of Proposed Work=:
vb !r fU
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item (Labor
Costs: Official Use Only
Labor and Materials)
I. Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/fawn Application Fee
2. Electrical S ❑Total Project Cosh(Item 6)x multiplier x
3. Plumbing S P Qther Fees: S
1. htahmtical (HvAC) $ List:
5. :Mechanical (Fire 'Total All Fees:$
suppression)
�— Check No._Check Amount: Cash Amount:
6. Total Project Cost: S �(�� 0 Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor Liccpse(ESL) _'9 9E 3 —Z4-1�—
/�(�• /F t
JOC)„C � Sll Otlt� L License Number Expiration Uale-
Mune of CS Hblder w c v. Z06 List CSL'rype(see below)
G-CJ Type: - Description
No.and Street-• s
U Unrestricted(Buildings Lip-to 35,000 w. Il.
R Restricted I&2 Family Dwelling
Cityfrown,State,ZIP C M Masonry
0L7 Z3 RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Tcle hone Emil address . D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Ifegistrution Number Expiration Date
111C Company Name or HIC Registrant Name
No.and Street Email address
Cityrrown,State ZIP Telephone
SECTION 6:WORKERS,.COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.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 Isivance of the building permit.
Signed Affidavit Attached? . Yes ..........❑ No........... ❑
SECTION 7n:OWNER AUTHORIZATION.TO BE.COMPLETED WHEN,
OWNER'S AGENT OR CONTRA:&OR APPLIES FOR BUILDING PERM IT
1,as Owner of the subject property,hereby out horize
t9 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:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby oft t under the pains and penalties of perjury that all of the information
coat ' a this ppli it
is and ccurate to the best of my knowledge and understanding.
Print( icr's or Authorized Agent's a e(Electronic Signature) ( Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or ant owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program),will nor have access to the arbitration
program or guaranty fund under 1M.G.L.c. I42A.Other important information on the HIC Program can be found at
wvvvv.mass.eov�oca Information on the Construction Supervisor License can be found at www.ntnss. ov�'dns
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) .(including garage, finished basementlattics,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+ubstituted for"rotal Project Cost'
CITY OF SALEA MASSACHUSEM
Bu E DING DEPARTMENT
120WWgaN mS7REET,3IDFiooR
7kL(978)745-9595
FAX(978)740-9846
KIIviBERLEYDRISOl7LL
MAYOR T3oMAS STREW
DIRECTOR cFFLzucpRopERjy/BtnDmocmmOjaR
Construction Debris Disposa/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 of MGL c40, 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 deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
�� �hl�hd Sal 4
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
drZ4 �
Si a ure of applicant
Date