17 POPE ST - BUILDING INSPECTION The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR Revised dlnr 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Divelling
c ' n For Official Use Only
Building P mit Numbe - ate Applied:
Building Olticial(PrH Name) Signature Date
SECTION t:SITE INFORMATION
I.i,ropert�A!Sr 1.2 Assessors Map& Parcel Numbers
I.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 R) Frontage(11)
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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2. O ner'of Record:•
j A 1"Ic N 4 CYi io
Name(Print City,State,ZIP ^
l'1 yQ�t�� o(I fir- 'ZtD-(99 l t ytg fa vQ lgwe i�• (°(�
No.mid Stree Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building'10 Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
l� Labor and Materials
• I. Building $ I. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: $
4. Mechanical (HVAC) S List:
5. Mechanical (Fire $
Suppression) Total All Fees: S
Check No. Check Amount Cash Amount
6, Total Project Cost: S��f e'o d ❑Paid in Full ❑Outstanding Balance Dueff:
49
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SECTION 5: CONSTRIICTION SERVICES
5.I Construction Supervisor License(CSL)
License Number Espimtion Datc
N:mie of CSL Ifolder
List CSL'Fype(see below)
No, and Street MInsulation
Des' "Li n
tricted ddin s u' to 35,000 cu. R.)
cte &2 Fmnil Dwcllin
Cityfl'ow ,State.ZIP
of-in Coverin
w and Sidin
uel Burning Appliances
tionIcle hone - Email address lition
5.2 Registered Home Improvement Contractor(HIC)
HIC Rcgistmtion Number I:cpirution Date
1-IIC Company Name or I IIC Registrant Name /
No. and Street
Email address
Ci /Town,State,ZIP "fete hone
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
1,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.
Pnnt Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,1 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. .
7ner's
k,. A/�JL�/' . eor Ar orizeJ Agent's Name Ilaecvonic Signature) pateNOTES:
er who obtains a building p
ermit to do his/her own work, or an owner who hires an unregistered contractorstered in the Home Improvement Contractor(HIC) Program),will not have access to the arbitration
or guaranty fund under M.G.L. c. 142A.Other important information on the HIC Program can be found at
s.�u�i�ca Information on the Construction Supervisor License can be found at��oxx,tua,,S.go�LL. ensubstantial work is planned, provide the information below:
Total Floor area(sq. ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. BJ 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 ofcooling system _ Enclosed-Open
1, "Total Project Square Footage"may be substituted for Total Project Cost"
i
1
CITY OF S-Ux-tii
PUBLIC PROPERTY
DEPARTMENT
UfO�Yat/O�rvr
w1O• 1 s VAGasa oo,snasr•%mix wa�oaurn o»-e
to.1'a•74s.7ses•IrAx 978-716944
HOMEOWNER LICENSE EXEIMMON
PkaN Frfgt
Data c 1
Job Location
Home Owner Addaww 1-1
Home Ownta Telephoee �' la
Present Mailing Address 1'l zsr
The currant exemption of"Homeowners"was extended to include owner-occupied
dwellings of taro Units or leas and to allow such homeowners to engage an individual for
hire who does not possess a liana%provided that the owner acts as supervisor.
DEFINMON OF HOMBOWNER
Person(s)who owns a pared of land on which bdsho resides or intends to reside;on
which then is, or is intended to be,a one or two &mily dwelling, attached or detached
structures accessory to such use wWor farm sanctum A person who consnucto more
than one home in a two year period shall not be considered a homeowner. Such
'?someownce shell submit to the Building Official,on a form acceptable to the Building
Official, that he/she be responsible for all such wort performed under the Building
Permit
The undersigned "homeowner'assumes responsibility for compliance with the State
Building Code and other applicable bylaws 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.
H0IAEOWNERS SIGNATL'RE ----
APPROVAL OF BUILDING INSPECTOR �+w
See other side for state code
`b CITY OF SM.&M. Uiss kCHUSETTS
13t;imING DEPART1LENT
110 W.tSHLNGTON STRFRT, 3iO FLOOR
TIEL (978) 745-9595
FAX(978) 740.9846
Ki\[SERIEY DRLSCOLL
MAYOR T Homu ST.PIEm
DIRECTOR OF PUBLIC PROPERTY/ButmmG COSLMQSSIONER
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 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 NIGL c
111. S 150A.
The debris will be transported by:
.)le-7 /f/A�
(name of 1-iiiuler)
The debris will be disposed of in
— (name of facility)
(address of facility)
�l f e�applicant
Jcbnvlf.b�: