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77 PROCTOR ST - BUILDING INSPECTION (4) Z� ems( SZ'1 2SZ The Commonwealth of Massachusetts CITY OF Board of Building Regulations and Standards SALEM q � Massachusetts State Building Code,780 CNIR Revised Var 2011 © Building Permit Application To Construct, Repair, Renovate Or Demolish a N One-or Two-Family Dwelling _ This Section For Official Use Only 1 Building Permit Number: Dat Applied: Building 011icial(Print Name) Signature, SECTION 1:SITE INFORMATION' LI Property Address: 1.2 Assessors Map&Parcel Numbers I� 77 1 rvcFor S ><LI Z t I.1 a Is this an accepted street9 yes no Map Number Parcel Number U ` 1.3 Zoning Information: 1.4 Property Dimensions: 'Coning District Proposed Use Lot Area(sy it) Frontage(B) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Reyuired Provided Reyuired 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? Municipal❑ On site disposal system ❑ Public❑ Private❑ Check if es❑ P p SECTION : PROPERTY OWNERSHIP' '`mOwners of Record: .5Q/e in n^� (01 - /i 5rin �Zohb[05 /� I 7 V e(Print) City,State,ZIP 77 - ao- P SP ' ts � -04 dwir-robb,MSrmKe No.and 'ect Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ 1 Existing Building❑ Owner-Occupied Repairs(s) ❑ Alteration(s) Addition ❑ Demolition ffiAccessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': I✓! d �C /I yh E� rnGetf_P1 a, !! SECTION 4:ESTIMATED CONSTRUCTION COSTS Itcm Estimated Costs: Official Use Only Labor and Materials) I, Building $ �OQ, vU 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Costs(Item 6)x multiplier x 3. Plumbing S 2. other Fees: S 4.Mechanical (EIVAC) S List: ( ) 5.Mechanical (Fire Total All Fees:S Su ressiun) Check No._Chick Amount: Cash Anmunt: 6. Total Project Cost: S C/ 0 ct • oil ❑Paid in Full ❑Outstanding Balance Due: MA t t E-n 101 z-ti n t-k , t SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder List CSL'rype(see below) Type - - Description . No.and Street U Unnstricted But in s tip to 35,000 w.tl. R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Routing Covering WS Window and Sidinx SF Solid Fuel Burning Appliances 00 1 Insulation Telephone Email address D I Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date f IIC Company Name or HIC Registrant Name No.and Street Email address Ci lfown State ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.QL.c. 152.§ 25CO , 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 AUTHORIZATIONTO BE COMPLETED WHEN: OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING.PERN11T 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 Nance(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. C)(_ �dv� )2obblh� ld r Print wner's or Authorized Agent's Nome(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 nut have access to the arbitration program or guaranty fund under NI.G.L.c. I42A.Other important information on the HIC Program can be found at ww.v mass eov'oca Information on the Construction Supervisor License can be found at www•.mass.eov�'dos 2. When substantial work is planned,provide the information below: Total floor area(sq. R.) (including garage,finished basementtattics,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 Type ofcoolingsyslem Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" Q7y of SALSA MASSAQmn B RMCD VAVMWU ]20 W.wmu�7�tS�7,3�i#� 1gL7�-9995. $>mF,RWrZamcm FdX 71498�6 MAYOR 7LtoduS7.P�ae DmecmxcFFU= /swnvacW&WaM Construction Debris Disposa/Affrdavit (required forall demolition and.renovation work) In aorordance with the shah edition of the State Busding Code, 780 CIWlt, Section ills Debris, and the provisions of MGL 00O,S 54, Bulift Permit if is issued with the condition that the debris nesultigg from this work shag be diseased of In a properly licensed waste deposit fadlity as defined by IWGL c illy s is6A. The debris will be transported by: Ofi Q C ci l( uY7 �'-" (name of hau er) The debris will be disposed of in: V()a bo d(I I-ram'i 5kf/0n (name of facility) 3 dy ies2` ��bo O l g 6 U (address of facility) ignature of applicant ate 3 CITY OF SALEM) MASSACHUSE TTS ( f y T BUILDING DEPARTMENT' 120WASHNGTONSTREET,3ADFLOoR TEL. (978)745-9595 KIMBERLEYDRISCOLL FAX(978)740-9946 MAYOR MiOMAS STTIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING CCAWSSIONER HOMEOWNER LICENSE EXEMPTION PLEASE PRINT. ,! � Job Location 7 �/l7 C l YlY Sryr°P f 5,?&, �1/f Home Owner Address 2 -7 121—p Present Mailing Address --;? /-o/-Xnd S �C / t 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 and requirements. comply with such procedures HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING INSPEC OR