78 SUMMER ST - BUILDING INSPECTION V The Commonwealth of Massachuscns Town of
Board of Budding Regulations and Standards
Massachusrus State Building Code, 780 CMR, T"eill
n Budding Dept
amom
Budding Permtl Application To Construct. Repair. RenovateDemolish a tltJrMof
Orrr. or T�ru-funu/Y svrlhng
This Sccuon IF u001114kial U O Pit
Budding Permit Number ate
Signature: ' l ��
Budding Comma /Inspector o Buildings Dat
SECTION 1: SITE IN RMATION
1.1 Property Address: �^ // 1.1 Assessors Map k Parcel Numbers
M Number Parcel Number
1.Is Is this an actor led strecO yes no Map
IJ Zoning Information: 1.4 Property Dimensions:
Zoning DistrictProposed Use Lot Area(sq R) Frontage(n)
1.5 Building Setbacks III)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
16 water Supply:(M.G.L c. 40.154) 1.7 Flood Zose Information: 1.8 Sewage Disposal System:
Zorw: _ Outside Flood Zone? Municipal O On site disposal system O
Public O Private O Cheek i(vesl3
SECTION 1: PROPERTY NBR�"►.sPt
1.1 aert o Reed I� GG_ 2�: ��
an*( Addseu rvice:
/
gitst Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKS(cheek aB that apply)
New Construction O Existing Building O Owner-Occupied O Repsirs(s) O Alterstio Ila) C Addition O
Demolition O AccessoryBldg.O N rol'Units_ Other O Specify:
Brief Description of Pro ed Work
SECTION 1: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Offlclal Use Only
Item Labor and Materials
1. Building f I. Budding Permit Fee: f Indicate how fee is determined:
O Standard City/Town Application Fee
2 Electrical S O Total Project Cost'(Item 6)x multiplier x
J Plumbing S - 2. Other Fea: S
a. Mechanical (HVAC) S List:
S Mechanical (Fire S Total All Fees. f
Sti ression
Check Vo. _Check Amount: Cash Amount-
6 Total Project Cost S 0 Paid in Full 0 Outstanding Balance Due
SECTION 3: CONSTRUCTION SERVICES
5.1 Licensed Construction Supers isor(CSL)
r, License'lumber Esprtauon Date
N,yoc of CSL- Ilplder List CSL Type(xv heluw)
Address T Description
U ;Unrestricted(up to 35•000 Cu. Ft.
R I Restricted 1&2 Family Owellm
Srynamre M 1 Massusiry Only
RC LItesidential Rocifirta Covering
Telephone WS I Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D 1 Residential Demohnon
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone ,
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.a ISL I M(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? Yen.......... 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.
Si store of Owner Date
�"SECTION 7b:OWNERt OR AUTHORIZED AGENT DECLARATION
6 1, S// , 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 knowledge and
behalf.
t 5
Rini
Signature of Owner or Authorized Agent —Date
Si tied under the pains and penalties o(perjury)
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 Sg have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.RS, respectively.
2. When substantial work is planned,provide the information below-
Total floors area(Sq. Ft.) (including garage, finished basemenUaltucs.decks or porch)
Gross living area(Sq. Ff) Habitable room count
Number of fireplaces V umber of bedrooms
Number of bathrooms Number of half.baths
Type of hearing system Number of decks/ porches
Tspeofcooltngsystem Enclosed Open
1 "Tool Protect Square footage••may he suh,muted for 'Total Project Cost"
CITY OF SALEM
lr��i
PUBLIC PROPRERTY
DEPARTMENT
LtI:. R I h.lRly „I I.
.0 U qi 1_'0 W. illIM;! 1NSITLET � �.\I r\1,
TfI:978-743-9;95 0 P:\Y:978.740-9846
Construction Debris Disposal Affidavit
(required lour all demolition and renovation work)
In accordance with the sixth edition of the state Building Code, 780 CMR section 1 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit tt - _ 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
I11. S 150A.
The debris will be transported by:
Z J�SQdsa�/
(name ut hauler)
The debris will be disposed of in
(name of aci ity)
a
laddress of lacility)
signature of permit applicant
-
,lane
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CITY OF SALEIM
PUBLIC PROPERTY
DEPARTMENT
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flta.r..8-715.9Ns • V%X 9'L7169aw
HOMEOWNER LICENSE EXEMPTION
MISS Met
Dab_404-- p
Job l.00atias
Home Owner Addreaa
Home Owner Telephone
Prevent Mailing Address
The current exemption of"Homeowners"was extended to include owner-0ccupied
dwellings of two Units or lea and to allow such homeowners to engage an individual for
Mrs who does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Persons) who oars a parcel of bmd on which he/she resides or intersda 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 OfIlcial,on a form acceptable to the Building
Ofilcial, that hdshe be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner"assumes responsibility for compliance with the Stab
Building Code and other applicable by-laws and regulations.
The undersigned "homeownee certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she,vill comply with said procedures and requi b
HOMEOWNERS SIGNATURE
.-kPPROVAL OF BUILDING INSPECTOR
See other side for state code