8 SMITH ST - BUILDING INSPECTION /J I �
The Commonwealth of Massachusetts
} Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 70 edition OF SALEM
Revised Junuury
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 2008
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Signature:
Building Commissioned Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1-1 PropCrty Addnss: 1.2 Assessors Map& Panel Numbers
I.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.3 Building Setbacks(R)
Front Yard Side Yards - Rear Yard
Required Provided Required 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?
Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: t,
1 c r h w `,'t 7 v
./� Name(Print) Address for Service:
r
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work': oaf S e' b a..
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building S 1 I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
?. Electrical S ❑Total Project Cost(Item 6)x multiplier x
1. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire - S
Su ression Total All Fees: S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S S y Q 0 Paid in Full 0 Outstanding,Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Superrlsor(CSL)
066603 S- 8- t2
=— V�&G A-\-L-a ell, License Number Expiration Dale
Namc ul'CSI.•I lolder List CSL Type(see below) [�
y CrveS Ave Sc,ko N+A
-r Description
:Address I U I 1lnmaricted(up to 35.000 Cu. Ft.
X R Restricted IR2 FamilyDwellin
Si Lure M M Only
9 7 g 7 3 S" 0 A S 7 RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
1IIC Company Name or IIIC Registrant Name Registration Number
d Adress
X Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 25C(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 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, in all matters
relative to work authorized by this building permit application.
Sianaturc of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
I, 5 oo as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application arc true and accurate,to the best of my knowledge and
behalf. l
CL
Print Name / 1 6- [U
Signature (honer or Authorized Agent Date
Si d nder the airs and ruthies of 'u
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 WL have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115,respectively.
2. When substantial work is planned,provide the information below:
Total floor area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq.Ft.) 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 of cooling system Enclosed Open
3. "Total Project Square Footage-may be substituted for"Total Project Cost"
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lob littr Addivir S vC..ScI. ST City/SumtZip
mrscb a copy of the werben'compamathm patsy deowni m pep(shewhy Ibs Po"sumbsr,and oepirasbw filth}
Failum to secure coverep s@ required under lectlon 2SA of NOL a. 152 can lad to the impooklm oferimind pmaiNw ore
r,no up to S 1.500.00 amUar one-year impoitotlment as well as cavil proeltioa is the rarm of a STOP WORK ORDER and a Ass
Or up to 5220.00 i Jay ipinse the violator. IN adHwd Choi a COPY ut this iratrmonl may be 1'urwurdad to the Oillce of
In,.,Cryatiuera ul'ehe n1A for insurance coveralls v.airIlLid ►
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O//reid vu ew/y< Oe nee wriN iw'him rteai,to bo.wwy/eted by rily or teerw a//Iri.d
City arruun: pr►mfNl.iceases__
lawnt.\ulhonty(circle one): -
I IluarJ u(IIeaICb 1. mudAl.y 1lrpartmane ). Cirytraw. Clerk 1. Electrical 611pecrae I. rtumbenR Incpeeter
6. thher .
l• nlart Penaw: _ _ {'hone s:
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
1 v./
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I:Q u'AJMV...CV)IMt[r 0 jdl l fl.•♦M.j1S'IMM
\ .I•'a t
v7W•�.9-0! a1'
(BOAS uircJtf tall d mol liun o Debris Dxl renovation work)
In rccunl uxe with the siatlt edition of the State Building Code, 730 CMR section 1 11.3
Debris. and the provisions of MGL a 30. issued
fth it t as defined by MGL
c
Duildin{{ Permit M _ is srued with the condition that the debris resulting ftom
roperly licensed w
this work shall be disposed of in a p rote disposal Y
111. S 150A.
The debris will be transported by:
f 1 C, (fc�r
IIla at hauler)
The debris will be disposed
doof1in
I ( � n Sl
Gt tM S C 67 1 \
1; II'1'xllityl
. platUfa of Iwrmit applieanl
(� r0
.late