5 RANDALL ST - BUILDING INSPECTION 6 7
ZY
I-lie ( o111111011"Culth of MaSS.KAILIWIIS
130,11d of ffilildmg Regulations and Standards Nit Nit 11' \1 I I
k `vJ&ssdCI!USettS SIJle Building Code. 780 CMR. 7"' edition S I
13 it i I d i iig Permit .Application To Construct. R e pa i r. I?e i i o v ale r I)e I I it)I N I J R,
One- ol Tu o-h Imittv Ou efling
I'llis Section For Official Ilse Only
Buildint: Permit Number Date Applied:
......latu e
Slu'llatul -: —0,�Xf 6 40
in
Bull ig inion
nnunt Woo/ 1-9114'r of Buildings Date
SECTION 1: SITE INF(MMA 110N
1.1 Property address: 1,1 %ssessors Map & Parcel Numbers
is th:h JL
1.3 Zo;iing Information: 1 4 Property Dimensions:
Zoning District Proposed Use Lot Area(,q to Holliage fiti
1.5 Building Setbacks (ft)_
Front Yard Side Yards Rear Yaid
RifQLJlCL! Provided ReqU11CLI
Provided ..... LICLJ
Water Supply: (.1.l.G L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
171 11r;,ate ❑0 Zone: Outside Flood Zone! Municipal 0 Oil site disposal sYslcill ❑
1 Check if yeso I
SECTION ?: PROPERTY OWNERSHIP'
2.1 Ownert of Record:
r) �
EL
Name,Pono Address for Service:
7-� Telephone
SIgTINure — k ,
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all thut apply)
1:1 Ex i s t i n Buildingg 0Owner-Occupied o RepauN(S) (s) 0 Adidlili'll 13
umber of Units— Other 0 Specily
rncrr, !:L1EAceNsory Bldg. 0 LIN
11rie: D�scrt:-iou or Propy7ysed Nv,-O. nq-
-C Y �I
4-
C�i V-LL/ +tA e
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials)
i, Building S 1. Building Permit Fee: Indicate h,i%% tee is dews mined:
0 Standard CityfFownApplication Fee
2. Electrical $ 0 Total Project Cost' (Item 6) x multiplier —x
1. Plumbing Y 1. Other Fees: S
List:
4. Mechanical (HVAC) 1i
5. Mechanical (Fire
S ire.s.,10n) Toed All Fees: S--
Check No. —Clleck Aun,,unr (',i,h Amount
0 Total Project Cost: 5
0 Paid to Full 0 OU(Standill2 BAZIMe
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Super%isor WSL)
Liecnx Numb I`.,pi r:wnn Dalc
\amr Ot CSI.- IIOIJcr
Lut Ctil_ T,pc i,cc hclo„I
\JJrCss I�' �' De?ell ,UOn
C t ..111111" nI 1 1�.l Nlll Cu. Ft
-- — R Resuiocd I X1 Fa111I1, D„clhue
IIgIIaIII rd >I Masonrn lhrly
RC Rc,iJentul Roolme Co,Cri[I,-,
fclepltone \'S Re,ia"1111 J \11nJO,� wa
1F RC,IJ0111ai .SOIid I uCl l 3wwne \ + i.m_hni.ilLniv j
D Ra,ideu U.d Denloliw.n
5.2 Registered Ilome Improvement Contractor 0110 — i cl13 a
HIC c� opmy VaA Orrf I,C R �7V \umbCr
c \ i
ame
Address I`r✓" / J O
_ .53 �,e s7�Q o� 7Fl(33Y 33>ZSy Expiration Date
Signature p Telephone
SECTION 6: WORKERS' COINPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 25C(6)1
Workers Compensation Insurance affidavit must be completed and submitted with This application. Failure to pio,lde
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. mall marten
relative'to work authorized by this building permit application. j.
I
Si nature of Owner Date
SECTION 7b: OWNER( OR AUTHORIZED AGENT DECLARATION
1, , as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knuw9edee and
behalf.
Print Name
Signature of Owner or Authorized Agent Date I YII
(Si red under the ions and penalties of er'u o
NOTES:
I. An Owner who obtains a building permit to do his/her own „ork.or an owner who hires an unregl,tercd a1n(rn,lor1
(nut registered in the Hume Improvement Contractor(HIC) Program), will not have access to the .uhitruion
program or guaranty fund under M.G.L. c. 112A. Other important information on the HIC Program and
Construction Supervisor Licensing WSL) can be found In 780 CMR Regulations I IRR6 and 110 R5. respec( ,cly
When ,utistantial work is planned,.provide the information below:
Total floors area 1Sq. Ft.) (including garage, finished basement/atncs. decks or porch,
(dross living area I Sy. Ft.) Habitable morn coum
Number of tueplaces Number of hedroonn
Nwmber Ot-h,uhiooms Number of hall/bath,
hype Ot heating system _ __ Number of decks/ purihes
Type Ot owhng s„lem,
i "Total Project Square Footage" may be ,UbSti(WeJ fir .:fot:d Pmlecl Cost'• __J�
CITY OF S.ULEM
PUBLIC PROPERTY
DEPARTMENT
Wray 130wAs NMM MWM•SMS NANAaa:s6r[s 01970
7VL 97674S-9S"* FNC 973-740.96"
HOMEOWNER LICENSE EXE1MFn0N
Pies"Print
Date 18 0
Job Location S 20n c1 '- I I st f ee�
Home Owner Address S 1Zo �d a I I S tree L -
Home Owner Telephone °I-J T S o v 3 s T rl
Present Mailing Address 5 7?ti vi ] cell St re e+
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 who.does not possess a license,provided that the owner acts as supe:visor.
DBFINMON 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 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 V
APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
'.I u%,. IN I,I I:I'T ♦ 5.\I r\I, \I,\;;.0
I I : 978--1 .9;95 ♦ I`:\Y:978.74.-9846
Construction Debris Disposal Affidavit
(reyuircd lix all demolition and renovation work)
In accordance will, the sixth edition of the Statc Building Code, 780 CNIR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Hermit k 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
I 11. S 150A.
The debris will be transported by:
fYlGrc. FYI er -r ISQY
(name of ha der)
I he debris will be disposed of in
I?e5co Gtnq.u <--
(narneof la lity)
j: t IA Sottnc (ne
(address of cility)
slgnaturc of ptnu applicant
date — —