79 SCHOOL ST - BUILDING INSPECTION (2) �O The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards inamomw
Massachusetts State Building Code. 780 CMR. 7'a edition Building Dept
Building Permit Application To Construct, Repair, Renovale Or Demolish a
One. or rrro-Famils•Dtrrlling
This Section For Official Usc On[
Building Permit Number � ate A lied:
Signature: / "0 - "�,�,,,
Budding Commissioner/Inspec f Buildings sit
SECTION 1:S T INFORMATION
it.1 Property Address: 1.2 ;lesson Map 8 Parcel Numbers
g
0
t.la Is this an tic led sirtna?yea no
Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions
Zoning District Proposed Use Lot Area(sq it) Frontage IR)
13 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Requited Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L e.so.f 7a) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public O Private
Zone: _ Outside Flood Zone? Municipal O On site disposal system O
O Cheek if s0
SECTION 2: PROPERTY OWNERSHIP' I-
2.1 Owner' f Record: S i MON
{—
Name Address for Service:
Si Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(Cheek ad that apply)
Nev, Conatnution O Esisting Building O Owner-Occupied O Repain(a) O Altenticn(s) O Addition O
Demolition a Accessory Bldg.O Number of Units_ Other O Specify:
Brief Description of Proposed Work": �C2�
Cif iol—I I wail I -I'D GaS fe
SECTION g: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Omclal Use Only
Ilem it hor and Materials
1. Building f 1. Budding Permit Fee: f Indicate how fee is determined:
O Standard CiryiTown Application Fee
2 Electrical f O Total Project Cost'(Item 6)x multiplier s
3 Plumbing f 2. Other Fees: f
4. Mechanical (HVAC) f List:
r Mechanical (Fire f Total All Fees: li
Su remon
Check No. _Check Amount: Cash Amounl:_
h Total Project Cost f 3"So O Paid in Full 0 Ouuundmg Balance Due
SECTION S: CONSTRUCTION SERVICES
9.1 Licensed Construction Supers isor(CSL)
a License.Number EspirationDoc
N,yoe of CSL Ilplder List(SL Type(Kv below)
A Jdress 7� Description
U Unrestrieied(u io)7.000 Cis. FI.
R Restricted 162 Family Dwellin
Sgputure .N %lasonev only
RC Residential floofrn Covering
7dephorw wS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Insiallalion
D Residential Demohoon
5.2 Registered Home Improvement Contractor I HIC)
HIC Company Name or HIC Regisuant Name Registration Number
Address
Expiration Oats
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. ISL/ ISC(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 Issuance of the building permit.
Signed Affidavit Attached? Yes..........O No...........O
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property hereby
autho oze _ •..Y _ to act on my behalf,in all matters
relati a to work authorize ,y this building permit application.
Si of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
t, (1M S ,as Owner or Authorized Agent hereby declare
that the temenu —information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
I S;olChy�
Print Name Is
/ i-y Cl
Signatwe of Owner*Authorized Agent _ Date
Si tied under the pains and penalties of
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 gg have access to the arbitration
program or guaranty fund under M.G.L. c. 1 a2A. Other important information on the HIC ProgIram and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110 R6 and 110 R3, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage. finished basementlanics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half baths
Tvpe of heating system Number ofdecksr porches
Tspeofcoolingaystem Enclosed Open
t "Total Project Syuare Footage"may he.uh,muted for 'Total Project Cost"
CITY OF $AIY. Nf
PUBLIC PROPERTY
DEPAIM,LENT
[!10lLfY OYlI.w
ywros 130 arAwwcru+s7.asr*sOW►„a NwaAoassrn otfl'o
tYi.9'.}7!}7S1S�F.�c 9'N+a7aN
HOMEOWNER LICENSE EXEMPTION
Ptew hint
I - OBI
Dow
Job Locados 7 9 S c�,--> ' S+
Home Owner Addreaa a m 0--
11613319 Owner Telephone 7 S? 71-// - LO 2 C
present Mailing Address -S 20--
'Cho current exemption of-Homeowners"was extended to include owner-occupied
dwellings of two Units or less and to allow such homeowners to engage an individual for
hire who doer not pow=a license.provided that the owner act@ err supervisor.
DEFINITION OF HOMEOWNER
which he/sh
person(s) who owns a parcel of land on he/she resides or intends to resider, on
which there is, or is intended to be, a one or two family dwelling, attached or detached
structures accessory to such use and/or farm structures. A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
-homeowner"shall submit to the Building Official.on a form acceptable to the Building
OfAciaL that he/she be responsible for all such work performed under the Building
permit
The undersigned"homeowner"assumes responsibility for compliance with the State
Building Code and other applicable by-laws and reguladons.
The undersigned "homeowner'certifies that he/she understands the City of Salem
and that he/she
ores and requirements
Bwlding Department minimum inspection proceed
Will comply with said procedures and equirements.
HOMEOWNERS SIGNAM"RE
,APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SALEM
I
�, � PUBLIC PROPRERTY
?` ','O DEPARTMENT
I ! HIu ,'•I I.
\I`.H It I_'e •fil ll.\'G'Ii,N$INLET ��.\II-�1,�1.\iiAf ilt il'I��:I'>•�l.
i'ef:v7tl•,';5=�595 1':1 x:978-746'9846
Construction Debris Disposal Affidavit
(required I'ur 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 he disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
lam` �\ S�f�cvJ
(name of naum,
The debris will be disposed of in
Quune of facility)
(address of facility)
signature of penrllt applicant
it y-o�
. date