4 PLEASANT ST - BUILDING INSPECTION (2) The Commonwealth of\Massachusetts
Board of Building Regulations and Standards CITY M Massachusetts State Building Code, 780 CMR $
Revised
Mar 2011
\ Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two Family Divelling
nThis Section For Official Use Only
Building Permit Number Date phed>;
Building Official(Print Name) .. Signature ,' f Date
SECTION L SITE INFORbiAT[O
1. Property Address: f L2 Assessors Map arcel Numbers
!p P2,6 ASA yr ST
L la Is this an accepted street? yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks (ft)
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:
Public ❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2:; PROPERTY OWN ERSHIEP
2.1 O nert of Record-
lGH 141k D LC was !SA-t —wf A4,1- a97 91
Name(Print) City,State,ZIP
No.and Street - Telephone Email Address evL to
SECTION 3: DESCRIPTION OF PROPOSED WORW'(check all that apply)
New Construction ❑ Existing Build ng❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ "wumberofUnits Other ❑ Specify:
Brief Description of Proposed Work:
) E,-40VAL 49,4: COLL. PSiNlr CH/M/VEtq
1-1,,1k-1AJ& 200P60 A /N UPS7— 4TeZS cU ALL
SECTION 4: ESTIMATED CONSTRUCTION COSTS
[tem Estimated Costs: Official Use Only-...
Labor and Materials
I. Building $ I. Building Permit Fee i Indicate how fee is determined:
❑ Standard City/ToWnApplication Fee
?. Electrical ❑Total Project Costa (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: $
1. Mechanical (11VAC) S List:
i. Jlaehanical (Fire $
Sii iressioit) _ Total All Fees: .S
`/ Check No. Check Atnoutit: Caslt Amount _
X Total Pt jest Cost: S d e7n ( ❑ Paid in Cull ClOutstandin• „g Bal;utce lhia:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor Liecnse (CSI.)
License Number E.xpinttionDate
Name of CSL (folder
List CSL Type(see below)
No. and Street Type - Description
U Unrestricted(Buildings up to 35,000 cu. 11.
R Restricted 1&2 Family Dwelling
City/Town, State,ZIP M N(asonr
RC Roofing Covering
1V5 window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Yele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
IIIC Company Name or I-IIC Registrant Name
No.and Street Email address
City/Town,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 Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING 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: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties oi perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authonzcd:4gent's Name(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(nut registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. Other important information on the HIC Program can be found at
www.mas,. ov ora Information on the Construction Supervisor License can be found at%vww.mass.govidL
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.) (including garage, finished basement/attics,decks or porch)
pros living area(sq. ft.) — Habitable room count
Number of fireplaces.-_ Number of bedrooms — —_--
Numbcr of bathrooms Number of halffbaths
fypc of haating system
h)pe of cooling sy;ront Foclosed_-- _Open _
j, I otul PfUi 'eC[ 1ir U91''! 1 UoIn-e I11:ry be ilibSnhllCd MI- I in.l1 Project C0it
,.
CITY OF S.UY.NI
PUBLIC PROPERTY
DEPAR . (ENT
UfOVllY L7•r'a.
`aA1Oe t�s v..o..w�S!rua7•a�•ti V�o�oa>erts onto
ra.•-V is-IS•s•v%&t7s.7+o.9sw
HOMEOWNER LICLNSB EXEMPTION
Plains Fries
Date
lob Location z- --
Horne Owner Address At""s 9nl T
Home Owner Telep hone 9 9-9 9 9<!r Zo 3 0
Presses Mailing Address /act.4s g�vT s T s F
The cunvd exemption oUlfomeownere was extended to include owner-occupied
dwellings of two Units or leas and to allow ouch homeowners to engago an individual for
hire who.does not possess a lieeoso provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of tand on which fWahe resides or intends to reside4 on
which there is, or is intended to be, a one or two family dwelling, attached or detached
Structures accessory to such use ardor farm structures. A person who constructs more
than one hone 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(sho 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 hdshe understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
Mill comply with Said procedures and requirements. O
HOMEOWNERS S[GNATLRE
APPROVAL OF BUILDING NSPECTOR
See other Side far state code
I
CITY Or SiULE1r 1,r( ,.?� ` ,• � L '+'�5511CHLSETTS
'
Bi:[LDLNG DEP.IR'I1lErT
120� WASHL�IGTON STREET 31°FLOOR
TEL. (973) 745-9595
FMX(978) 7-W-9346
1<I�tDERLEY DRISCOLL
AIfAYOR 'MONLU ST.PIERRa
DIRECTOR OF PCOLIC PROPERTY/BCILDL%IG CM131ISSIO.NER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition Of tile State Building Code, 780 CMR section It 1.5
Debris, and the provisions of tNfGL 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:
tie (fs4L4 ./ a—A-Jk- }r.--/�7 UL
(name ufhaulur)
'['he debris will be disposed of in
(name of facility)
— —(address of taaility)
1
signature ufpermit applicant
�=3
date
i
!I