37 PROCTOR ST - BUILDING INSPECTION (3) ck /500),
"File Commonwealth of Massachusetts F
l Board of Building Regulations and Standards CITY ITY OF
l Massachusetts State Building Code, 780 CMR SALRevised.1/ur?O/I
n Building Permit Application"ro Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
This Section For Official Use Only
Building Permit Number: D, Applied:
a o
Building Official(Print Name) Signature Dat.
SECTION 1:SITE INFORMATION
1. Pro er ddress eJ` 1.2 Assessors blap&r Parcel Numbers
IZ!t C) 1-
1.1 a Is this an acce ted street?yes no %rap Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions.
Zuning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 1Vtiter Supply:(M.G.L c.40,§5l) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system
❑
Public❑ Private❑ Check if es❑ P p y
SECTION2: PROPERTY OWNERSHIP"
2.1 Oa ert of Recoye}
�I»s�( ;aYl £�"lJ o 1pi vc.�t\N�ea(�lity state,zl PCYI N)Q C���7(7
'�} UC�e�Y Csi C13`b 7zF� b ` GstYjPVt IIGS CO �UL CnDlk
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ I Number of Units_ I Other ❑ Specify:
0 B ief Description of Proposed 1Vyrk-: Y
L
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item E itnated Costs: Ofllcial Use Only
Labur and Materials)
I. Building c$ 0 I. Building Permit Fee:5 Indicate how fee is determined:
❑Standard Citylrotvn Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing .S �Oi�) 1. Other Fees: S
1."'Icchanicai (HVAC) S --42y� List:
5. :Mechanical (Fire Total Ali Fees:.S
Slip[xessiun)
Check No.—Check Amount: Cash Amount:_
6,'rutal Project Cost: .S 2 'o 0 Paid in Full 0 Outstanding Balance Due:
SECrION5: CONs'faucTIONSERVICES
5.1 Cuustruction Supervisor License(CSL)
License Number E.xpirutiun Date
Name of CSL[[older List CSL'rype(see below)
"type' Description '
No.and street
U Unrestricted(Buildings tip l0 35,000 cu. It.) .
R Restricted l&2 Family Dwelling
C'ily(rown,State,Zip M Masonry
RC Roaring Covering
WS Window and Siding
SF Solid Fuel Buming Appliances
hismotdution
Nle hone Email address D Delition
5.2 Registered Home Improvement Contractor(111C)
HIC Registration Number Expiration Date
111C Company Name or HIC Registrant Name
No. and Street Email address
t Cit frown State ZIP Tcle hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(VI.G.L c.152.§ 25C(6)),
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this nt'tidavit will result in the denial of the Istuance.of the building permit.
Signed Affidavit Attached? Yes..........0 No...........❑
SECTION 7a:OWNER AUTHORIZATION.TO BE COMPLETED WHEN.
OWNER'S AGENT OR CONTRACTORAPPLIES FOR BUILDING PERMIT
[,as Owner of the subject property,hereby authorize Cllo O—is- ._L Y�O
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Norte(Electronic Signature) Date
SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION
By entering my name below, I 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. j
Li
Prim h ter's or Aulhor� Name;mie(Electronic.Sigtmture) Z / D te�
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(1-I1C) Program),will no 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.eov'oe❑Information on the Construction Supervisor License can be found at www•.mass.sov�hlLs
2. When substantial work is planned,provide the information below:
rotal floor area(sq. R.) (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 `Dumber of half/baths
rype of heating system Number of decks/porches
l'ypeorcooling system. Enclosed Open_
1. ..Total Project Square Footage"may be;ubslituted tor,rutai Project Cost"
t�
- V.
CITY OF S:U E4Nt, —kSSACHUSETI'S
? r t ' BL1LDLL%GDEPARTNI&NT
130 CV.ISHLYGTOY STREET, 3'0 FLOOR
`. <,.. " T EL (978) 745-9595
F.-,x(978) 740-9M
IU�tBERLcY D[L[SCOLL
A1YO:1 T1 o.%tAsST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/BCILDCYG COSDtISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Coda, 730 CMR section I 11.5
Debris, and the provisions of NIGL e 40, S 54;
Building Permit t« is issued with the condition that the debris resulting Prom
this work shall be disposed of in a properly licensed waste disposal Facility as defined by tbIGL c
I 11, S 150A.
I'hc debris will be transported by:
(namc orhauler)
The debris will be disposed of in
_ -- (narne of r'acdity)
-- (address01tdtacility)
sturelic
permit applicant �'�`-�J
- -- .1�2U I�
date
QTY OF SALEM, MASSAC HUSETTS
BUILDING DEPARTMENT
120 WASHNGTON STREET,Y"FLOOR
9 TEL. (978) 745-9595
KIMBERLEY DRISCOL FAX(978) 740-9846
I,
MAYOR TY-IOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date
Job Location
Home Owner Address
Present Mailing Address
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 V