5 POPE ST - BUILDING INSPECTION The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
/ Massachusetts State Building Code, 780 CMR Revised Alar 1011
dl;
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date.Appiiedr
Building Olticial(Print N:une) ign Date
SECTION 1:SITE INBORtNIATIONS
1.1 ro erty Address: 1.2 Assessors Nlop&Parcel Numbers
�n� - Sc(ptut .Nl� Df°i�o
I.la Is this an accepted street?yes Ito_ Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq it) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yams Rear Yard
ReyuireJ Provided Required Provided Required Provided
1.6 Water Supply:(hI.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑
Public❑ Private❑ Check if vesCl
SECTION2: PROPERTY OWNERSHIP"
2.l wn rt of Record: '5q[e � AAA D 1�
I FRe
time(Print) City,State,ZIP
one SI" ab83259� aV1jxvV we6Ls' °IMAnI.r�"
Nu.mid Shot Telephone Emaill Addre.
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
EDenlolition
n❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
of Proposed Work=: ��u ti� o
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Itcin Estimated Costs: Official Use Only
Labor and Materials)
1. Building S 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost](Item 6)x multiplier x
3. Plumbing S P Qther Fees: $
4.Mechanical (HVAC) S List:
>. :\lechanical (Fire S "rotal All Fees:S
Suppression)
Check No._Check Amount: Cash Amount:_
6. Total Project Cost: _S 20 O.VD ❑ Paid in Full ❑Outstanding Balance Due:
'(� �� [614 -(5
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Dale
Name of CSL Holder list CSL'rype(see below)
Type Description
No. and Street .
U Unrestricted Bail din Lip-to35,000 cu. 11.
R Restricted I&2 Family Dwelling
City/rown,State,ZIP M Masonry
RC Ranting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(IIIQ
HIC Registration Number Expiration Date
HIC IC Company Name or HIC Registrant Name
No. and Street Email address
Ci /town,State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e.152.1 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 W HEM
OWNER'S AGENT OR CONTRACTORAPPLIE3 FORBUILDING PERMIT'
1,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Dale
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,)hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print OWne 's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. 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 nor 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
W W+v mass eov:'out Information on the Construction Supervisor License can be found at ww�!
2. When substantial Work is planned,provide the information below:
'rotal tloor area(sq. It.) `A .(including garage,finished basement/attics,decks or porch)
Gross living area(sq. It.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
'rypeof cooling system Enclosed Open
3. "total Project Square Foocag�'may be substituted fur"Total Project Cost'
CITY OF SALSA MASSAMUSE TTS
! BuaDu rG DEPART eNT
120 WAS MCWNSTREET,3`RWR
7kL(978)745-9595
KIlv18ERLEYDRISODLL FAX(978)740-9846
MAYOR TrIOMAS STYLERRE
DIRECTORcFPLzucPROPERTY/BtuDm ccmasgomR
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 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:
�v�a-chi�ei r
(name of hauler)
The debris will be disposed of in:
(name of facility
(address of f cility)
Sign re f applicant
Date
QTYOF SALEM, MASSAQJUSETTS
BUILDING DEPARTMENT
120 WASHNGTON STREET,3R0 FLOOR
TEL. (978)745-9595
F
KIMBERI.EYDRISCOLL FAX(978)740-9946
MAYOR T7fomm STTIERRE
DIRECTOR OF PUBLICPROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date
q�zs�l S
Job Location
Home Owner Address Poet_ safevn AAA P /Q/;7-O
Present Mailing Address YbQ,& Tale v mtk DIQ(-1-0
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
APPROVAL OF BUILDING INSPECTOR — ---