55 TREMONT ST - BUILDING INSPECTION (2) p The Commonwealth of Massachusetts
r-I Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR Revised Mar LEM20//
Building Permit Application To ConstrA Repair, Renov e Or Demolish a
One-or Two- mil Dwelling
This Sec on For fficial U Only
Building Permit Number: D to plied: 6 //
Building Official(Print Name) Signature Date
SECTION 1KITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
5, �dAJ) 5T
I.I a Is this an accepted street?yeses no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(It)
1.5 Building Setbacks(ft)
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:
Public 50 Private❑ Zone: _ Outside Flood Zone? Municipal;a On site disposal system ❑
Check if yesO
SECTION 2: PROP TY OWNERSHIP'
2.I Owner'of Record:
/1?1Q/Il' T. E3ULCfH.9lGr�>
Name(Print) y,State,ZIP
Ss 7�ldy�' SI' 9�Sr-7�is:��9 e✓�9�:&rr!/.,1����or�,Psr_..r
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ >umber of Units Other ❑ Specify:
Brief Des cri tion of Proposed Work':
C�Lli;ofP/ro
1—h,,- fiy�.o� }nd c� foe N fiYC lsLi> E,�ijj��4 x;z
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials) Official Use Only
I. Building $ cv 1. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ /<<j'� 0 Paid in Full 0 Outstanding Balance Due:
SECTION,5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No. and Street Type Description
U Unrestricted(Buildings up to 35,000 cu. R.
R Restricted 1&2 Family Dwelling
Cityffown,State,ZIP M Mason
ry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances !
1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
H
HIC Company Name or HIC Registrant Name IC Registration Number Expiration Dale
No.and Street
Email address
City/Town, State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 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:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information
coot 'ned in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agenl's Name(Electronic Signature) V Dale
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
wNvw.rnass.¢ovioea Information on the Construction Supervisor License can be found at www.mass.aovRlns
2. When substantial work is planned,provide[he 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"
CITY OF S.U.EM
PUBLIC PROPERTY
DEPARn, LENT
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rm 9'L7119sft f F.%x 918,746964
s
HOMEOWNER LICENSE EXEMPTION
Pfeaw irlre v Job Ucatlos ✓S % ,o/.,�a�— Si S.�.IGi! .�?.9
Home Owner Address 6S oc,07' .ST /J10
Home OwW Telephotre 7S7-7/75-3 969 ellL 781- yi?,/D
Pteaest Mailing Addreaa ,��� :3ncrr,fszcp � �irsll/1sT, .✓�'T
The current e:empdoo of"Homeowners"was extended to include ownar-occupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
hire who.does not possess a license,provided that the owner acts as supervisor.
DP,FNMON OF HOMEOWNMt
Persons) who owns a pared of land on which he/she residea or intends to resider on
which there is, or is intended to be, a one or taro 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
,i meownar'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 "homeownee certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
.Drill comply with said procedures and requiremen
HOMEOWNERS SIGNATWU
APPROVAL OF BUILDING CiSPECTORa G
See other side for state code
CITY OF SM.&M. A-1SSACHUSETTS
• BL'IIDIING DEr.1RT.LENT
120 WAsHLYGTON STREET, Yo FLOOR
ILL (978) 74S-9595
FAX(978) 740.9846
ICl\®ERLEY DRLSCOLL
.MAYOR THO.+ua ST.PtT�nRa
DiltEcroz OF PLBLIC PROPERTY/BCIIDLYG COMMISSIONER
Construction Debris Disposal Af idavit
(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 c 40, S 54;
Building Permit # 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
l 11, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit applicant
date
dibnvl(I•a '