53 TURNER ST - BUILDING INSPECTION }
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2vn1tTS 570 � 25"
The Commonwealth of Massachusetts
°uDd Board of Building Regulations and Standards RECEIVED ���CITY O
( Massachusetts State Building Code, 780 ECTIOHAL 5E e
Revised Mar 2011
Building Permit Application To Construct, Repair,Renovate Or Demol' f
1 ,
One-or Two-Family Dwelling % SEP
This Section For Official Use Only
Building Permit Number: Date A ¢lied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Prope Address. ! 1 1.2 Assessors Map&Parcel Numbers
�V rit Cl J Ilece a t)
Lla 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 ft) Frontage(ft)
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❑ Private❑ Zone: _ Outside Flood Zone?Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
DEMOS 2.1
g�2z O err of Rec�ord•r, J= a/97 o
Name(Print) City,State,ZIP
No.and Stieet Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Bri Description of Proposed Work':-
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ ,/ fo 1. Building Permit Fee:$ indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costs(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 p p 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
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License Number Exptratlon Date
Name of CSL Holder •�r t
r a "7 4
List CSL Type(see below)
No.and Street pi i3 Type Description
U Unrestricted Buildin s u [0 35,000 cu.ft.
Crty/Iowm,State,ZB' R Restricted I8,2 Famil Dwellin
M Muse
RC Roofin Coverin
WS Window and Sidin
SF Solid Fuel Bunting Appliances
I Insulation
Tele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expnation Date
HIC Company Name or HIC Registrant Name
EanNod Street Email address
own 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 PERMPC
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:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained ' his applicat��n is�is true and accurate to the best of my knowledge and understanding.
X , COAP -0 �{ - 2o1 �
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 gov/oca Information on the Construction Supervisor License can be found at www-.mass eov/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"
r-
CITY OF SALEM, MASSACHUSETTS
BUILDING DEPARTMENT
120 WASHNGTON STREET,3m FLOOR
\� TEL. (978) 745-9595
KIMBERLEY DRISCOLL FAX(978)740-9846
MAYOR THomAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONMSSIONER
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 # 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 r t ansported by:
(name of hauler) .
The debris will be disposed of in:
IVP,-A
(name of facility)
(address of facility)
Signa re of applicant
Date
QTY OF SALEM, MASSACHUSETTS
BUILDINGDEPARTMENT
>str` 120 WASHINGTONSTREET,3"D FLOOR
TEL. (978) 745-9595
FAx(978) 740-9846
KIMBERLEY DRISCOLL
MAYOR TY-IONIAs STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONEVIISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date Oq O
Job Location S3 T✓/ncr STic��
Home Owner Address
Present Mailing Address
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 INSPECTOR / i