41 STATION RD - BUILDING INSPECTION 4;0(5
I x The Commonwealth of Massachusetts
t k Board of Building Regulations and Standards R r F
Ql Massachusetts State Building Code, 780 CMR INSPE f1E0 IVIC S
s; Revise Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling 1014 KAY -2 A 3
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name) Signature Date
SECTION l:SITE INFORMATION
I I/ S.1 Prof J1
perty Address: Sa/e /h O �7 1.2 Assessors Map& Parcel Numbers
Lta �an d , �
1.la Is this an accepted street?yes Vzno Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
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Zoning District Proposed Use Lot Men(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (NI.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 13 Private❑ Zone: _ Outside Flood Zone? Municipal[3 On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Qwnerl of Record:
r/Pdme c K C16t fK. Sq lem, A'(/f 0/rj 7 G
Name(Print) City,State,LIP
Ul yi Ste,?;un id. 79FX07,35 tasi_f1zt
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied Repairs(s) R1 Alteration(s) arf Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I j Other ❑ Specify:_
Brief Description of Proposed Work': UJI'll keplIncePoriS+.n; Gt/aad /ha lt6la / 611
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dar n/on iheuSe-
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ I. Building Permit Fee:$ _Indicate how fee is determined:
❑Standard City/town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6) ultiplier x _
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees:$
u Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ / CU jj, C C ❑paid in Full ❑Outstanding Balance Due:
fy�ut a
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
C 'VL::cia
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
Ci 'y tt SK rll`t�
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu. ft.
R Restricted 1&2 Family Dwelling
City/Fown,State,ZIP M Mason
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
'rele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
H
HIC Company Name or HIC Registrant Name IC Registration Number Expiration Date
No.and Street Email address
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152. § 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 .......... ❑ 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, in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
/ cont 'ned in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.sov/dps
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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® Harvard Pilgrim ® HarvardPilgrim
Healthcare HealthCareofNezaEngland
Harvard Pilgrim Fitness Reimbursement Form
To be filled out by Harvard Pilgrim Health Care SUBSCRIBER only.Please use blue or black ink and print all information clearly.
When to submit this form:
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CITY OF SALEM, MASSACHUSETTS
BUILDING DEPARTMENT
It 120 WASHINGTONSTREET,3"O FLOOR
y n 'ItL. (978) 745-9595
FAX(978) 740-9846
KINMERLEY DRISCOLL
MAYOR TY-IOMAS STTIERRE
DIRECFOR OF PUBLIC PROPERTY/BUILDING COMNIISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
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Date L `J `1 n I
Job Location 7 U/(woe, lCOaa ,�e/d?rl�j/� C✓(!`70
Home Owner Address / / JA,t ah 12d
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Present Mailing Address V stwliol
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 that 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" assumes responsibility for compliance with the State Building Code and
other applicable by-laws and regulations.
The undersigned "homeowner" certifies that he/she understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE C" '"✓
APPROVAL OF BUILDING INSPECTOR
PARSONS AND FAIA INC .
60 LEWIS STREET
LYN N MASSACHUSETTS 019 2
( 617 ) 593 - 7927
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THIS IS A TAPE SURVEY BASED ON THE
SURVEY MARKERS OF OTHERS AND THE LINES
OF,OCCUPATION .THIS PLAN WAS DRAWN FOR
MORTGAGE PURPOSES ONLY.THIS PLAN WAS
REFERENCE : NOT PREPARED FOR RECORDING PURPOSES,
DEED DISCRIPTIONS, CONSTRUCTION
THE PREMISES SHOWN ON THIS PLAN VERIFICATION OF PROPERTY LINE DIMENSION
IS No-r LOCATED WITHIN THE FLOOD BUILDING L6NE OFFSETS,FENCES OR LOT
ZONE. FIRM MAP* CONF I GURATIONS.ONLY A PRECISE
INSTRUMENT SURVEY CAN DETERMINE ALL
I HEREBY CERTIFY THAT THE BUILDING(S) THE ABOVE,
SHOWN ON THIS PLAN ARE APPROXIMATELY MORTGAGE INSPECTION. PLAN !
LOCATED ON THE GROUNDS AS SHOWN
THEREON AND THAT THEY CONFORM TO 1 � n®
THE DIMENSIONAL REQUIREMENTS OF THE �'A!o •C� �i� �
TOWN/CITY OFSAco,,44AJS-\tkM A c���, /iG LAWS ��®®,,,,
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