74 PROCTOR ST - BUILDING INSPECTION (2) I �� The Commonwealth of Massachusetts
8 CITY OF
DID
Board of Building Regulations and Standards SALEM
Massachusetts State Building Cade, 730 CMR Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building-PermitN ber. Date, e`d:
1 z Szz
Building Official Print Name). - .Sign Date
SECTION 1:SITE INFORMATION
L1 Propert Ath�ress: C`\ 1.2 Assessors Map&r Parcel Numbers
� �rac�"oc
1.1 a 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 ft) Frontage(R)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Own rt of Record: M
me(Print) City,State,ZIP
--).y Q<� s� a�S 3\1
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)New Construction❑ Existing Building❑ Owner-Occupied 16 Repairs(s) Elf I Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs:Labor and Materials) Official Use Only
1. Building $ j. aor-) I. Building Permit Fee:$ I Indicate how fee is determined:
�. Electrical $ El Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier- x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List: .
5. Mechanical (Fire Suppression) $ Total All Fees:$
42 y
6. Total Pro ect Cost: $ Check No. Check Amount: Cash Amount:
j ❑Paid in Full ❑Outstanding Balance Due:
A/_4;N L a '_P
r �
SECTION5: CONSTRUCTION SERVICES
5.1 Constru ton Supervisor License(CSL)
License Number E pit, on Date
Name of CSL Hol er
� � List CSL Type(see below) �]
Cac a�
No. and Street Type - Description
U Unrestricted 2 Family
a el ing cup If.)
R Restricted 1&2 Famil Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I I Insulation
Telephone hone Email address D Demolition
5.2 Registered Ijome Improvement Contractor(HIC) \1-\a1V
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
NH1uQ=L Email address
City/Town,Stale,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 1,52. ¢ 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 Is§uance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN.
OWNER'S AGENT OR CONTRACTOR:APP IES'FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize \(7--
t4 act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'ORAUTHORIZEDAGENT 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.
Print Owner's or Authorized Agel is Name(Electronic Signature) I 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 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.1>ov'oca Information on the Construction Supervisor License can be found at www.nurss.�,ov.'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"
1
CITY OF SALEN15 TNU. sSACHUSEM
• 13UIMNG DEPARTMENT
130 WASHNGTON STREET, 3" FLOOR
TEL (978) 745-9595
F.mx(978) 740-9846
KIN{gFRt FY1=Y DRISCOLL
MAYOR DR THO.NWST.PIERRS
DIRECTOR OF PUBLIC PROPERTY/BCILDNG COMMISSIONER
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 It 1.5
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 MGL c
111, S 150A.
The debris will be transported by:
(name of h lei
The debris will be disposed of in :
(name of facility) \
(address ot facility)
signature of perms applica
date
air�,nra,x
CITY OF SuEm, 2ANSSACHUSETTS
131 11.01I IG DEP. M.1ENT
t• 120 WASHINGTON STREET, 3-FLOOR
TEL (978) 745-9595
FA.,((978) 740-9846
K1.\fBERi t~Y DRISCOLL THO1%WST.PtERR8
MAYOR
DIRECTOR OF PUBLIC PROPERTY/HhB.DLNG COMMISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/ElectriciansJPlumbers
Aninlicant information N Please Print Legibly
Name(Busitx&Organizatiorulndividual):�`L�Address: —l`1 Q'Cc`"_Iz,
City/StatcJZip,:2s� a Phone#P�-I'C— "3o`i— `itVNc1
Are you an employer?Check the appropriate box: Type of project(required):
I.D I am a employer with 4. 0 1 am a general contractor and 1 6. ❑Now construction
employees(full and/or part-time)." have hired the sub•contraclors
2.9 1 am a sole proprietor or partner- listed on the attached sheet t 1• ❑Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working.for me in any capacity. workers'camp.instarsnce. 9, 0 Building addition
(No workers'comp.insurance 5.'0 We.are a corporation and its
officers have exercised their I0.0 Electrical repairs or additions
required.) .
3.0 1 am a homeowner doing all work right of exemption per MGL I L❑Plumbing repairs or additions
myself.(No workers'comp: c. 152,§1(4),and we have no 12.`Lv-FJ' Roof repairs
insurancerequired.)t employees.[Ngworkers' ,
comp,insurance required.) 13.tbp Other
•Any appilcum chat chucks box itl must al,o fill out the soclian below showing their wmimse cempenwlon policy Information.
s I bvneuwmtn who submit this affidavit indicating]hey ate diatom all+wrk and then hire outside contractors must submit a new,airdavit indicating such.ry s k
16;mmetoss that chick this box must anochsd an a"liuma sheet showing tho name of the sub. ftlruWra and their workers'camp.policy infomtadon.
l um an employer that Is pravfding worker'compensation lasarance for my employeex Below/a die pollcy and fob site
injornratiam
insurance Company Name:
Policy 4 or Self-its.Lie. 4: Expiration Date:
Job Site Address: City/Statedzip:
.%tt3ch a copy.of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of NIGL c. 152 can lead to the imposition of criminal penalties of a
tint up to S1.500.00 ond/or one-year imprisonment,as well as civil penalties in the form of it STOP WORK ORDER and a line
of up to S250.00 a Jay against the violator. 13e advised that copy of this statement may be forwarded to the Office of
Invusligmio s of the DtA for insurance coverage verification.
/do hereby cerrljy rut rlrr his and penalties ojperlary that the brfurmadmr provided above is true mid correell
S', at I ata• J-
OJliciol use only. Oo not write in this area,to be completed by city or town ajjJrhr1
City orTuwn: Permiu7.1censel
Issuing Authority(circle one):
I. Board of Health 2, Building Department J.Cityfrown Clerk 4. Electrical inspector 5. Plumbing Inspector
6.Other
Contact Person: _...... - .---._. Phone#:
1