21 SALTONSTALL PKWY - BUILDING INSPECTION (3) C'umm�onar;thh u(,b1;IssaehuselU
IlavJ MALL ding Regulations and Standards CI i'Y OF
/) Massarhwcns Slane Building Code, 79U C NIR ti,\LG.\I
r
Building Permit Application To C'tmslnicL Repair. Renovat Demulis a
One- or Tuvr•Funulr Utrelliu.p
This Section Fur 011iciul Use()fly
Building Permit Number: _ Date Applied: 42
Iluilding 0111cial(Print Mane) Signalurc Dulc
SECTION 1: SITE INFORMATION
L I Pr arty Address: 1.3 Assessors Map JI Parcel Number
I.la Is Ihis an acce ted slreel? es no Map Number I'urccl Nwuher
I.! Zoning Information: 1.4 Property Dimensional
/oning District Proposed Ilse Lot Area(sy 11) Frontage(it)
1.5 BuildingSetbseits(R)
Front Yard Side Yams Ruar Yard
Required I'ruvidcd Required Provided Rcyuirud Provided
1.6 Water Supply:(M.G.I.e.40. §34) 1.7 Flood Zone Informatlont 1.8 Sewage Disposal System:
Public O Private O Zone: — Outside Flood Zarne? Municipal O On site disposal s)stem ❑
Check if cs0
SECTION3: PROPERTY OWNERSHIP'
2.1 nert of Rscordt
0" /GFA K JCh 5 c Eh F4 DI4 70
Munn 111 City.State.' ..
t/�,y�rvvac�z� �1cw� 97 lr� .lGs— ��It
No.and Street relephona Email Address
SECTION]: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ I Repairs(s) ❑ 1 Alterallon(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ mberof Units_ Other O .Specify: t
Brief DescriplionofProposed Work': e-v6otc ytr5-r w& {)Ease
SECTION 4: ESTIMATED CONSTRUCTION COSTS
hem Estimated Costs: WOW Use Only
(Labor and.Materials) Y
I. Building S I. Building Permit Fee: S Indicate how tee is determined:
'. r1cclrical S ❑Standard City Twsn Application Fee
❑Total Project Cost'I Item 6)x multiplier
J I'lunihin5 S '. Usher Fees: S
i J. \Idclt.mical ,II\- \('f i List:._
Vcdlauiad IFrre i ----.—_—.-- --- .-- __ . .. ._
�u •+rcsmnl rnr:d \Il
( 11V A No. ( hccA.\nunurt: Ca,h -\nnnun:
Tuwl 1'rnjcci Copt: i OOr 0 0 O P.iid in Full ❑Outsiandiog IIA.mcc Due:
�'W,IZ
�—
SF("1'IO,NS: fONSI'RII("IFIONSFMI('FS
5.1 Construction Su lie risur License
I icenw Nunlhcr . ... I viraiion Ilene
\'wneul'01 IIokler IIst01. l)pel•eeheluwl,._,_
No. .uld Slreel t l I hlrestridcd l l)ud,w 3 11 10 31. 00ol. I J
R lu'tricwd IS? Pamil M%ellifill
Cipi I',ren, suety./II' -- — —_ \I Slasuu
RC Roolin Omerin
A'S window,uld qulin
SF Solid Fuel Ilurning \ppliwues
1 Insolution
1'cic hone Fnsail uddnsi D Demolition
!,2 Registered Ilume Improvement Contractor(HIC)
IIIC' Itcgbuatiun Numher livpir Lion Date
IIIC Company NJnw or I IIC'Itagislrum Nunes
Flllail'Jddreaa
No. wtd Strict
Ci -Town, State ZIP )hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152. 23C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the deniel of the issuance of the building permit.
Signed Affidavit Attached? Yes ..........O No...........O
SECTION 791 OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorise
to act on my behalf, in all matters relative to work authorized by this building permit application.
Date
i'rint Owner's Nwne IElcctrunic Signuture)
SECTION 7b:OWNERt OR AUTHORIZED AGENT DECLARATION
By entering my name below. I hereby attest under the pains and penalties of perjury that all of the informatiun
contained in 's application is true and accurate to the best of my knowledge and understanding.
I'rinl wneisur:\utharoeJ,\geIII iN;unc lP.IcUru'lie Slyn.nural
Des
NOTES:
I. .\n Owner who obtains a building permit to do his her own work,or an owner who hires an unregistered cuntractur
( wt registered in the Hone Improvement Cuntractur(HIC) Program).will no have aecele to the arbitration
Program or guaranty fund under M.G.L.c. I4211. Other important int'urmation on the HIC Program can be Ilnund at
Infornation on the Construction Supervisor License can be found at St" 'Ill`
N hen substmrtial work is planned,pro%ide the information below:
f +lal flour area Isy. IT.1 _ ____.._t incluJing garage, linishcd basement attics,decks ur pordnl
it.l Habimble room count _ ..
(iroii llv ringarea 114. ...... . .. _... . .
\unlberal'lin•placef \unlhcrofhcdaxnrs . .
\uulher,ll'halhremus _. _ _ -- \onlbcrol'hall'halhs
I\pe+rt hc•mng s„Imn \unlhcr of decks- pordlcs
f�I•o 1�onhng :)acm
I'110o'cd lnpan
1 "1" 1.11 1'mlevt \ilu'Jre Foolawe Ilia) he'uh,111utcd for"t+slal Frujep Co't"
CITY OF S.U.EM
PUBLIC PROPERTY
DEPARTMENT
u.ouas+r o.scaL
Nwrae t b w�w�,�au slue�snuw we�oR>sm Ot f'0
M 9'2-745-95"•FAX f'L7�69W
HOMEOWNER LIMNSB EXEMMOM
Pleas "I /
Date "
Job Location
Home Owner Address
Home Owner Telephone ,�i 6A- 7 ,fk,4
?room Mailing Addrm zt .Sra�s� may. Sn, �u. .v1,9 vt4 �a
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 possese a licmae4 provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on whicb hdde resides or iatende to reside,on
which there is, or is intended to bs,a one or two family dwelling attached or detached
structures accessory to such use and/or fast structures. A person who constructs moro
than one home in a two year period shad 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"aumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations
The undenigned "homeowner"certifies that he/she undentands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
.vill comply with said procedures and requirements
HOMEOWNERS SIGNATLRE
APPROVAL OF SUILDING DiSPECTOR
See other side for state coda
CITY OF SALEM, NL-1SSACHUSET17S
BUtLDIIVG DEPART\IEINT
120%VASHINGTON STREET, 3" FLOOR
TEL (978) 745-9595
F.*—v(978) 740-9846
"KItCBERIEY DRISCOLL
.tii iYOR THONtAs ST.PIERRa.
y DIRECTOR OF PUBLic PROPERTY/HCII.DLVG CONINUS5IONER
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 111.5
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
I 11, S 150A.
The debris will be transported by:
StL
(name of hauler)
The debris will be disposed of in
_A)t)~5j 17 t C-f4 z )±a'
(name of facility)
(address of Facility)
signature of permit applicant