10 PLYMOUTH ST - BUILDING INSPECTION The Commonwealth of Massachusetts IVED
t Board of Building Regulations and Standards Roll SER4 CESCITY OF
Massachusetts State Building Code, 78WFDTIDIit SALEM
lysed Mar 2011
Building Permit Application To Construct,Repair,Renovate Op er91is1}$ L O
One-or Two-Family Dwelling 1415 �Pi
\\ This Section For Official Use Only
W Building Permit Number: Date plied:
J Building Official(Print Name) 'signature 72at
1 SECTION 1:SITE INFORMATION
1.1 Prope Address: S 7-4
ssessors Map&Parcel Numbers
D Ty
1 11a Is this anlaccepted street?yes_ umber Parcel Number
02 1.3 Zoning Information: roperty Dimensions:
Zoning District Proposed Useea(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided I Requimdf 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?Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
L dt.t, ,-d L A9209-yi'Y`-C ff
Name nt).,/ ity,State,ZIP
No
.and Street Telephone Em AddresaSL s r�M
SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repays(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed rkZ: 0 L
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ h I
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
\ Su ression $ Total All Fees:
X' Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 3 O� `p Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
f
License Number Expiation Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type - Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC 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 7tr:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering in na bel w,I e ttest under the pains and penalties of perjury that all of the information
con ' ed in is is on i nd urate to the best of my knowledge and understanding.
Print Owner's or 6kutho a Agent's Nam lectmnic 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
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(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 half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
QTY OF SALEM, MASSACHUSETTS
. ) BUILDING DEPARTMENT
s1jr s 120 WASHINGTON STREET,3"D FLOOR
TEL. (978) 745-9595
FAX(978)740-9846
KIMBERLEY DRISCOLL
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/B UILDING CONINIISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date
Job Location /O �Mocl l-'1 S 7
Home Owner Address Scr P
Present Mailing Address Ca
The current exemption of"Homeowners"was extended to include owner-occupied dwellings of two
Units or less and to allow such homeowners to engage an individual for hire that does not possess a
license, provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel 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 structures 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 Building Code and
other applicable by-laws and regulations.
The undersigned "homeowner" certifies that he/she understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE r� Wj
APPROVAL OF BUILDING INSPECTOR
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CERTIFIED TO. rHE HUIVUH87*0H MORTGAGE CO.
NOTE: This mortgage inspection was pre
I FURTHER SATE THAT IN MY PROFESSIONAL
pared specifically for mortgage purposes and is not to ce re OPINION thr principle structures and accessorylied SH OF
upon as a survey. Northam Associates, Inc. accepts '�' outbulld;nps� CONFORM
responsibility for damages resulting from said reliance-Sy 'L�
anyone other than the said mortgagee and its ass' ns in G with the setback requirements of the local zoning
oonnection with its proposed mortgage financing said o _ ordinances and that there are no encroachments of mnior
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