5 POND ST - BUILDING INSPECTION -- T- —- —
-= file ('onu oimealth oI 1lassaihusetts t
t Ifutard td IiullJi ig RCQU1,11101IS .Ind Standard, \II NIL, II' (III 1
\lavuchusetts State Iiullding ('r,Je. 750 l ''\IK. T edition I I 1�I
l, .. T
I,ALI
liuilding Permit :\pplii.tut,n To ('un>(ru Repair. Rentttate lJr Ik ntull,lt a R.
)it,,- to Tar •Woih 1 (,1 it'le:
Thu 'ectian For )tficl l ISe Daly
li IIIIJInI Penn❑ Nil then __ ate pplicil
swilalu1e tI-- �/ — — - -- — ' /�S� --
Hi IIIt, a a(Ulll„IU n o I IC In,IK.It ILL,I JI IIE,
SECII( r SITI.' INFORMA'FMN
I.I Pro crl} Iddre : — � 1.2 \ssesscrs Map & Parcel Numbers
a\l Nu a then I'.u.rl .Xwnhtl
I I.I Is thl� an accepted ,trees" tee__ no___ f P ___ -----I
'._)... 'oni:tg lq,fornwiion: 1.-0 Pirtmerty Lia:re elan->:
Zunury Dislnet._— Yn:poord C'se _-- I LuI l•,y to
1.5 Hicilding Setbacks (f )
I Front Y'arJ
Itcynu.J----- -Provided Required Pro.-ovd R.yuu eJ _ PI;�,i.IrJ
LE 1Ycter Sltpply: (.1A.G.L e. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone1 \huucq,al ❑ On ,uc Jul,+rsul ,y,lein O
Puhli. G' Pncaie ❑ Check It ves❑ �—
SECTION 2: PROPERTY O`AiYERSHIP'
?.; Ow ert f Record• , '/✓^,7v JkL
_
Name lPlllill Address lot Set".1.�
r-Nkw
ature — Tclephone — _—
SECTION 3: DESCRIPTION OF PROPOSED WORK"(check all that apply)
Construction ❑ Existing BwlJing ❑ Owner-Occupied ❑ Repausn) ❑ :vierarnrnl s) ❑ :\JJlm... ❑emolition Accessary.Bldg. 17 Number of Units__ Other ❑ Sptcny
Bficf De•cripuun rt Proposed Work-, Y ----
SECTION J: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Vern Il.ahor:md Materials) _ . _ _. -_ .. J
I BuJJlltg S /O�� I I. Budding Perms Fee: S___ Indicate hlrtt tvc is Jclennined-
" ❑ Standard Cilv/'1'own :\pphcunun Fee
2. Eileetnral _,� ❑'rota) Project Costr I Item 0) s multiplier _ s
t. Plumhlne S '. Other Pees: 'S
1. Nlechar l 11MILCI S 1_oc -----------
i. :'tfechamral IFoe
rlrt.Il :\II Fee,: S
I ('heck No ('heck .\mount:
'' h final ProJett Cost
5�(�7� ❑ Paid ut Full ❑ Outst.utdnte B; ❑ P.oJ In Full ❑ Ou1stalldl ne Bal.lnte P(IC ..-
SECTION 5: CONSTRUCTION SERN WES
5.1 Licensed Construclioat Super\baar (Csi.)
I "t SI, I'j,c 'C'. h,1...
I 111r'o 1,1.d I I I
%I t hli,
j,
S1-1 j I ci 11,ii
_D
5.2 Registered Home Impro%ement Contractor iIllCf
Ill( ( milpalps ss"llic of 111c, Hegntraul Name
D'ac
feleplimle
SECTION 6: WORKERS' CONIPENSATION INSURANCE AFFIDAVIT (NI.G.L. c. 152. § 2506))
Workers Compensation Insurance affidavit inusa be omilpleted and uhnimed with this appli,armn Failure In plo, de
this affidavit will result in the denial of the Issuance of the building permit.
Signed Attidimt Attached? Yes 13 No 0
SECTION 7w OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Owner the ,hj�ci piopcitv hereby
1, as( . . ...... hereby
awhi Irate
.cork authoriml by 1hts building permitappitcation.
S-j¢iij[ureol Owner Date
SECTION 7h: OWNEWOR AUTHORIZED AG ENT DECLARATION
1. -- asOwneror ,Auihoit/cd \,,entheichydeclaic
that the.statements and information on the foregoini: application are true and accurate, to the best of my knotN icdge and
behalf.
Print Name
Stenatureot Owner or Awhori/ed Ngent Date
Signed under the pams and penalties of perjury
NOTES:
I. An Owner %hit obtainss a buil
dmg per
mit to d o hit/her own stork: or anowner who hit CS an LIM e�i,iei ed I L
snot registered in the HomeITVr� (HIC) Program), will nit( hate ccCSN to the
program orguaa" v fund under .G I- c. 141A 0(herimportant Information on the Ill(* Pn,y1,11n ,L11d
2 When ub,tantial work is planned, plot de the information helow
Total tl,,(,rs area i.Sq, I-'[.i
H.Lhiiahle room count
NUFTIherct tiicpl,ices-- Numher of ho-Iro,,in,
Nwmhei of b.ohn,,in, NLMihcr ,,t halt hJ!hl
I \pe ,t heating v,iern N(Iolhef I't JCL k" J)�'I-he,
k I,c 11L, .N,tem 1,1, 'cd
1. I'o(al Pnyect Square Ft,,f,1gC ITIA.\ be 'Uhstituted her r,,t,,i p,je,(
CITY OF S.ULE-M
PUBLIC PROPERTY
DEPARTMENT
,J.ff.""
VArM wASUPIMOM Sifesr•SMJCK NAMAOR.'srfls 01970
no-VW7154S" • FAX 971-74&M"
HOMEOWNER LICENSE EXEMPTION
Please Print - —
Date
Job Location
Home Owner Address
Horne Owner Telephone
Preen t Mailing Address 01 ,.
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
him who does not possess a licensek provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Persons) 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 dwellin& attached or detached .
structures accessory to such use and/or farm structures. A person who constructs more
than one home in a two yew 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"assume@ 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 inspection procedures and requirements and that he/she
will comply with said procedures:and requirements.
HOMEOWNERS SIGNATUTRE n
APPROVAL OF BUILDCYG LIISPECTOR 4�
See other side for state code
CITY OF SALEM
y ;
PUBLIC PROPRERTY
DEPART'.vIENT
I A ..• \>I lI.I r # S.\I I \I. NI.\mil\( .. �, 111
III /�3 '4i ');V; 0 1 \X. 97,1 '4='IS4n
Construction Debris Disposal Affidavit
(rcyuired li)r all demolition and renovation work)
In accordance %%ith the sixth edition of the State Building Code, 780 CMR section 1 11.5
Dcbris, and the provisions of'IviGL c 40, S 54;
Building Permit 4 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
I 11, S I50A.
The debris will be transported by:
(name of hauler)
I he debris will be disposed of in
P 4
(numr ul fac�i lily) -_
.Ignaturco mit .y\plieant
/y
,late —