54 TREMONT ST - BUILDING INSPECTION (3) The Commonwealth of Massachusetts RECEIVE[ OF
WBoard of Building Regulations and StandarWSPECTIONAL S. RVIVX
Massachusetts State Building Code,780 CMR Revised Mar 2011
Building Permit Application To Construct,Repair,Renovatj fiI�gi ollsj a P Z: 4 9
One-or Two-Family Dwelling
00 This Section For Official Use Only
0 Building Permit Number: to Applied:
DO
Building Official(Print Name) signature Date
l SECTION 1:SITE INFORMATION
1U(1 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
_a T _EMDA1T ST
L la is this an accepted street?yes lw� no Map Number Parcel Number
\� J 1.3�Zonning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Requred Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: _
:SON INN .54LEM
Name(Print) City,State,ZIP
54 TRetAONT ST q�r`6-241-So4(, 1 4fl D� i` QMfA] �• W✓r1
No.and Street Telephone Email Addr s
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied �, Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ 1 Number of Units I Other ❑ Specify:
Brief Description of Proposed Work': 6-etJ1C-90tL utA%trU i
New E1Fc-cSz[c�.t N� Pere. foo.UccicQe Fw� � � 1 Ic�.e ,n �e(1t z,
SECTION 4:ESTIMATlD CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $
❑Total Project Cost'(Item 6)x multiplier x
3 3.Plumbing $ 2. Other Fees: $
a. 4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
Suppression)
Cheek No. Check Amount: Cash Amount:
6.Total Project Cost: $ 2 0�C ❑Paid in Full ❑Outstanding Balance Due:
CWA-
3S
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
Lis[CSL Type(see below)
No.and Street Type Description,
U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
CityiTown,State,ZIP M I Masonry
RC I Roofing Coverin
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street
Email address
Ci /Town,State ZIP - Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AMDAVIT(IYI.G.L.c,'152.g 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 7ae OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES.FOR BUILDING PERMIT `
I,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 pedury that all of the information
cc tained in this application is We and accurate to the best of my knowledge and understanding.
>s
Own or orized Agent's Name(Electronic Signature) D to
NOTES:
Z
1. Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
r egisteredd 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
wtvw.mass.gov'oca Information on the Construction Supervisor License can be found at wvrw.mass.ro€ v/dns
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"
QTY OF SALEM, MASSAO-1USETTS
BUILDING DEPARTMENT
�F YI
120 WASI-IINGTONSTREET,3"°FLOOR
TEL. (978) 745-9595
F
KIMBERLEYD1tISCOLL FAX(978)740-9846
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING C01aUSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date D% ,11g1/5 \
Job Location -54 1 EAAON T ST , 5A{EItd M A
Home Owner Address SEEM E AS AP.oyC
Present Mailing Address H6 C A-8oT ST . -]1PLe LLq MA
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
APPROVAL OF BUILDING I PECTOR
OTY OF SALE14 MASSAGiUSETIS
BIALDING DEPNt7MENT
120 WAsffiNGToN S7REET,31D FLOOR
7kL(978)745-9595.
F
KIIvIBERLEYDRISQOLL FAX(978)740-9846
MAYOR 7YiCRu1As ST.PIERRE
DIRECTOR OF PLIDLicPROPER7Y/BuliDm ocmmm0mR
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 c40, S 54; Building Permit g t is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
OuJO `t(ZuCi: .
(name of hauler)
The debris will be disposed of in:
(name of facility)
GEOK(:7&7CwAl , 14A
(address of facility)
ignature of applicant
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Date
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