79 PROCTOR ST - BUILDING INSPECTION it � .. ---- -- -- ---- - ----------- - - --
I he (',nn lion ka.r.JIh t+I %1as sal.till Neils i
1 ti1 BojiJ tJ Butldint.: Rc_nlaiionN and StaiidurJN Nil `I( lilt\1 11 )
\ 1 \IaN.a.husells Stole IluilJing Code. 'So( 'MR, 7" cditwn \I
Ir r
IiuilJin�' I'rrnut :\ t lir.uittn )-a ('tmarurt. Rr air. Itrnttt,tte Ur I).•nit,li.h .t
(htr- nrruo-flimlrlhrlhn�
I'hisSe;umfor )thciall'NeOnly
F11wlJine Pcrnul N' rr.'
� HwlJ;np ('nnunn.i,n ev In.pr.Ian liu I m U.uc
SECI'ION I: .SII'F. INFORMA FION
1.1 Property dress: 12 \Nsessurs Map K ParCal NU(111)er1
I la IN Ihu tit eCtep(ed ,uu( te, � nu_-- f Map Su niher I �i.� \aloha
_ f y
1 l.3 Zoning Information: 1.4 Property Dimensions: j
, Building- g ,- `Setbacks
ur, ..N.._ Side 1'aid, isr,yff`inn 'Rear'1arJ
1.5 Bmldm Selhacks (ft)
fr rnl
--4
Rryuu rJ Pr11VJed ReyuocJ PmtiJed HeyuurJ fn�t iJrJ
j 1.6 Water Supply: iNt G L:. 10. ;,I 1.7 Flood Zone Information: 1.8 Sewage Disposal S)stem: -- j
Zone: outside Fl�xtJ lone"
PLIHIC ❑ Pro.ale❑ —_— — .Vumupal ❑ On site Jnlxt.al st.tnm _j
❑ _
Check it vrs❑
IF SECTION 2: PROPERTY OWNERSIIIPI
12.1 Owners of Recor :: - ( �y
Address for. Cl s ice:
73c 7
,rt.t rc _- - Telephone
i• DESCRIPTION F PROPOSED WORK check all (hat a ilv ---�
SECTION .. DESC'RIPT O O O ( pl _ t
New CunsOUCtion ❑ E sung Building Ors net-Occupied 1.1 1 Rep_ums is\Iler:unnl,t-❑ AdJo,;o ❑J
T
Demtth ,in ❑ AcCesm"ry BIJg. ❑ Number of linos Other ❑ Specily
Dtli�e'!)cscnpuoo ut Proposed Wurkr:
00
S: CTION ESTIMATED CONSTRUCTION COSTS
--- Esn m:oed Cnsts:
Item I t1 ahor .inJ Niumnnlsi Official Use Only
— t— ---—--- -
0 600 j I. Building Pcnnn Fee: 5 Indicate hurt ICC r. JeIcun1nCJ:
i---- - ^ ❑ Standard City11'uten Apphcattnn fce
L2. 5 V �G _-_.- ❑ Total Project Cost' (Item GI s multiplier --_ s
Plumbing 5 0,00 '. other fees: 5
1 NitChamwl Hl":\CI ) Q. Q Q
'-� Ntct haniC.J !f oc - --- ..
lit tre N,wni S 0 . 0 O f„tal Ah feet- 1
('heck .Wit \mount- l'.nft \nip n nu
o I olal Project Cost I 's �(, 000 0 Paid in F•.tll- ___ 0 (hmLunlotg D.iLon c Uue_
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed ('oll.structioji Supervisor lt'SI.t
APW
_ I 1
,".._,tC T1.j kill k' (100 ti _7
�R�R,,�o,,led I& 1:.11,116 Itwrllule
%I I Mils
Rt Rc,ld,11ii-il
I)JI", wd r
D)
5.2 Registered Iforne Improvement Contractor I MC)
Fit('Colollallv Nallic or MC Registrant Naine
F\l-liwo,m Date
Signature relepliolic
SECTION 6: WORKERS' CONI PENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. 17-olure III Ill—ide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Atfidavit Attached? Yes .......... 0 No
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
V to act on my behalf. In .111 olJIt'_lS
:lu(( orp c
!e!a[Ivc to woik authorized by this building permit application.
Owner
S E
Signature of Owner Date
SECTION 7b: OWNFR' OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
(hat the statements and information on the foregoing are true and accurate. to the best Ili my knowledge ;Ind
l -
behalf.
Print Name
Signaiurew Owner orAuthorized Agent Date
(Signed under the[!jins and penalties ill perjur))
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who lures ,it uniegi,[eicd .,ultra. I'll
(not registered in the Home Improvement Contractor (1110 Pr(,gramI, will not hose access :o Ineat holan,Ili
program or guaranty fund tinder M G.I. c. 1.42A. Other Important infi,imation ,m the MC Pr(,grani ind
Construction Supervisor Licensing WSLI ran he I'mind in 780C,%IR Regulations 1 10 R6 ,oid 110 145, respecuscly
2 When suhmannal work is planned, pro,,tde the inimmation below:
floors area Sq. F1.1 including garage. finished hj.seirient/atti�N. J"ks
I (iio,s li,,mL area iSy. Fr.) Habitable r.,,Ito I:t)um
I Numbered roeplaces _— NillobCI' M hedroI,in,
Numhe( or hmhiooms Numher Ili
NLlinher ,-I Jc,k,/ pI-j,hc,
1 .\Ile nit
foi.d Pwjeo Sklume rjl.lv be Ub1IIILJICd t,,r Prt,lect
CITY OF SALEM
PUBLIC PROPRERTY
„ ,• < DEPART'./IENT
.� �$1'?IJ-r ♦ S.\III,
III 'i'3-Vi-•RVi ♦ 1:\V 'i78 '4.- ).i44.
Construction Debris Disposal Affidavit
(required lix all demolition and renovation work)
In accordance ith the sixth edition of the State Building Code, 7SO CMR section 1 1 1.5
Debris, and the provisions of lN1GL c 40, S 54;
Building Permit k is issued with the condition that the debris resulting front
this work shall he disposed of in a pruperly licensed waste disposal facility as defined by MGL c
t 11, S 150A.
The debris will be hansported by:
food.
(name of hauler)
I he debris will be disposed of in
(name of facility)
taddress of facllily)
Ig na mre m permit applicant
7- ) V v 0
ate
CITY OF sm-Em
PUBLIC PROPERTY
DEPARTMENT
IU1aE9L�Y NlfflY
VAroa 13e wABONGTM STUM 9 SALE{VAUACHUM s*1970
TM 9104-9S"9 FAx:978-740-9i46
HOMEOWNER LICENSE EXE.MMON
Pk m Print
Date 7- /y-09-
T - A m
Job Location Pk 0 �(2 S S'R I'll
Home Owner Address -7 q' /r 6c -A- S- P m
Horne owner Telephone q7C - 7 S - 3C
- Sodom
Present Mailing Address -7 9 ee io 0-to
The current exemption of-Homeowners"was extended to include owner-occupied
dwellings of two Units or less and to allow such homeowner$to engage an individual for
hire who 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"assume*responsibility for compliance with the State
Building Code and other applicable by-laws 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.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code