24 VALLEY ST - BUILDING INSPECTION � /I -- I'he C'unununsveallh of blassachuseus
Q Iloard of Building Regulations and Standards CI IN OF
NtassaCIMSetts Slue Building Code.-M CNIR NALENI
Reviled lbu'_I11
U Building Permit Application To C-onslruct Repair, Renovate Or Dcnsolish a
One.or Tau-fiundr Divelliog
This Section For Otlicial Use Only
Building Permit Number: Da plied
fluff ding 011icial(Print Mum) I, gData
SECTION I:SITE IN R31ATION
1.1 Property Address: 1.2 Assessurs flap S Parcel Numbers
Rti vw-af S -
1.I a Is this an occe ted creel?yes no--- Map Number Purcul Numher
1.3 Zoning Information: 1.4 Property Dimensions:
Lolling District I'nrpowd Use Lot Area(sq Ill Frontage(11)
1.5 BuildlntSetbacks(R)
Front Yard Side Yunls Rear Yard
Required Provided Requimd Provided Required Provided
1.6 Water Supply:(M.G.1.c.40.§54) 1.7 Flood Zone Information: 1.8 Sewaaa Disposal System-
Public Outside Flood Zone?
IhrbHc❑ Private❑ — Check if ycs❑ Municipal❑ On site disposal sl stem ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 �O1�w�ner'of
.Be�brl Record-,F
-Ilmd!;4asia lAwnp�rl� dr/�nC IP,V)'1 /n JOtS Qt�'�Q
Mena(Print, ` City.Stale.ZIP
2 v V0.l l c�u S'�• 47fi'-744796 5 -- �
Nu.unJ Street telephone Email Address
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Aiteratlon(s) ❑ 1 Addition ❑
Demolition ❑ ,Accessory Bldg.❑ Number of Units_ Other ❑ Spccily:
Brief Description of Proposed Work":IMAT WdOu
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 011lclal Use Only
(I.abur and \laterials)
1. Building S 1. Building Permit Fee: S Indicate how tree is determined:
❑Standard City?own Application Fee
'. I:'kctrical S ❑Total Project Cost'i Item 6).1 multiplier
1 I'lumhing S v. Other Fees: S .-
1. MQ%11.111i:al ill\ W) 5 List:
\Ic.'hanical (Pita ------ -------•-- ----- . . .
Cu,+rcssiun) S rotal \II Fces: S_.._
1 Check No. ( heck:\nuntrm: C.uh \m,�uus:
1'ulal Prn'cet Cus Oa s 5 /V ❑ Paid in Full 0(lutsl:mding II.t,mcc Dua:
SECTIONS: ( ONSI-RUcriONSERVICES
5.1 U 1
Na-nw i—,I 17S—I I 1—o-ldc r— L'SI, 1'�krx:1scc
I)PC Description
sirvvt I I hirrvtrioccl I IN11 illus 110 10 3'-011()cu. tLl
R Ht:.,(ri%:tcd l&2 F."I'd M%elli"
L itik"I"Imi.State./III %I Masud
C Riwiin Uncrin
Window wd Stdin
SF Solid Fuel Ilurning Appliances
I filsillution
I elvIiholle Fmail addrvss D Demolition
5.2 Registered Ilume Improvement Contractor(1111C)
IJ1,n1hr F%pirmioil Wig
JIIC Compact) Manic or IIIC I4,:il6trkia Njow
No. mid Street Finuil address
City/Town. State,ZIP relephone
SECTION G:WORKERS'CONIPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 2SC(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 or the building permit.
Signed Affidavit Attached? Yes ..........a No...........13
SECTION 7a: OWNER AUTHORIZATION TO BE C0111PLETED%VHEN
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 Owncr's Name(Electronic Signature) Date
SECTION 7b:OWNEWOR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the a-ins land penalties of perjury that all of the information
contained in this application is true and accurate to icbest I'myknowledge and understanding.
.... V U10 Iq , I/ —Z 3 —/2
Print Owner's or: whori -JAgoit'4 Name(1: . tic 1411aturo) Rule
NOTES:
1. An 0\%Aier who obtains a building permit to do his,her own %vork,uran owner who hires an unregistered contractor
0 u i I
not registered in the Hume improvement Cuntfrtour(HIC) Program).will have access to the arbitration
do d Ik 2.
7.3 IvPG L c- 1 4
'1 .1
program or guaranty fund under M.G.L.%:. 142.A. Other inipunant information on the HIC Program can be hound at
\%%%,% I information on the Construction Supervisor License can be found at
e a d c
2. \%lien substantial%�kork is plalined,provide the information below:
.. 1,
a
rotal fluorarvaiikl. 11.1 garage, finished basement,attics,decks or rorch i
h6tigarcaiscl. it Habitable room count
Number of liedrokillis
\11111hvtot half h.1111i
I')pe All heating i)item \,,i,her ofacchs, porches
pe ofcooliI16 1)itcffl .01'ell
rofal ni.,N [,e iib,titItvd flor I*otal Project Cost"
BAG ST E R
DUMPSTER IN A BAG"
BAGSTER
a Will
SrFR'
4\, 1
� E
t4 Vq}it;StorertC f5 l l fb qui).t2'"L ' �:CYGI i' $chendll)d'y6111`�dI1Hf S$YX
Yourneest It ILA ca npact enpu9 khaki t ptp ,af�CXJ d ca�{m6 or Iy phone Ar tf h3
aPwzys urnirard ttFpady k� njfebtf ar v5aee„ s Bane!A ast eeCtiv�
usd hers RF�F sL �dht prxer�av�ltsns, ydl�spo.Sa] erviieg
f wy L9 a latss. rbgr a 'lVlairenl'erxt;�r a a
44` � �ff3 � at4 ttTFIEBAGSTER COlul , , i
( s"'17 x,.'1 d' '�iL47� 's,:
New England Collection Fee
A collection fee of$164 per Bagster bag applies at the time of collection. Additional Bagster fa
g, bags collected at the same time and address are$140 each. Collection fees subject to change
and applicable taxes and fees. Each Bagster bag is a single use product;bag and contents will not
be returned after collection. '?
New England Service Area
Bagster bags located within the following areas will be collected by Waste Management."
Contact Customer Care if your location is not listed,but might be within our service area. `
„. Connecticut Maine New Hampshire
-Fairfield County -Androscoggin County in the following zip codes: -Belknap County
-Hartford County 04210,04222,0424o,04250,04252 -Cheshire County
' -Middlesex County 04256,04258,oan4 -Grafton County
-New Haven County -Cumberland County in the following zip codes: -Hillsborough County
-Tolland County 04011,04015,04021,04024,04029 -Merrimack County
{ 04032,04038,04039,04055,04062 -Rockingham County
Massachusetts 04069,040]1.04074,04079,04084
-Bristol County 04085,04092,04096,04097,0410t -Strafford County
04102,04103,04105,04106,04107 -Sullivan County
-Essex County
4260
-Franklin County York
County in 04110,owing Rhode Island
-Vork County in the following zip codes'.
-Hampden County 03901,03902.03903,03904,039W -Bristol County
-Middlesex County 03906,03907,03908,03909,04001 -Kent County
-Norfolk County 04002,04005,04027,04030,04042 -Newport County
-Plymouth County 04043,04046,04064,04072,04073, -providence County
-Suffolk County 04083.04082,04090,04093 -Washington County
-Worcester County -Sagadahoc County in the following zip codes'.
04008,04086,04287,04530,04548
04562,04579
'Yard waste not accepted In all areas.Visit wevitbebaguacom or 1-877-789-BAGS(2247)for more Information."Collection serve provided by a local operating
subsidiary of Waste Management,Inc.The Bagster bag is provided by WM raged,LLC,a Waste Management company BegsteP numpster in a Bag*,and BUY FILL.GONE
are registered marks of WM Eagan,LLC. 104,105,106,111,198-vl0.11
BAGSTE R WASY.2.MEM
DUMPSTER IN A BAG'
q 2y GAGSTER
� wnL
i srFa
® •. • Q at va��,,
� t
t 1 a u. gi»' 9 dTPk,- 4z3'
�st� - � �praYect�s�bm�stlta�� � � ��s�can�garrt�rr,"�
�roneCesitetdeu n*dor
debasoradatama�o: HEBAGSTBR.CUNT
tompleto: 9"-877=789-BAGS(2247)
Cargo por recogido en el area metro de New England
Up cargo de recogida de$164 se aplica a la vez de la coleccibn. Cara bolsa Bagster adicional recojida al
mismo tempo y en el mismo domicilio es$140 cada una. Cargos estan sujetos a cambia e impuestos
aplicables. La bolsa de Bagster es on producto que solamente se usa una vez,la bolsa y su contenido no sera
devuelto despues de ser colectado.
New England area de servicio bolsas
Las bolsas de Bagster que esten en las siguentes areas seran recojoas por Waste Management."
Comuniquese con Servicios de Clientes si su sitio no esta incluido en la lista,pero quiza este dentro de nuestra
area de servicio.
I t1
Connecticut Maine New Hampshire
-Condado de Fairfield -Conda de Androscoggin en Its siguentes codigos -Condado de Belknap
-Condado de Hartford postales: -Condado de Cheshire
-Condado de Middlesex 04210,04222,04240,04250,04252,04256 -Condado de Grafton
-Condado de New Haven 04258,04274 -Condado de Hillsborough -y
-Condado de Tolland -Conda de Cumberland en Its siguentes codigos postales. -Condado de Merrimack
04011,04015 04021,04024,04029,04032 -Condado de Rockingham r"
Massachusetts - 04038,04039:04055,04062,04069,04071
-Coralde Bristol 04074,04079,04084,04085,04092,04096 -Condado de Strafford
-Con de Essex 04097,04101,04102,04103,04105,04106 -Condado de Sullivan
dado
-Condado he Franklin 04107,04108,04109,04110,04260 Rhode Island
-Condado de Hampden -Conda de York en Ids siguentes codigos poetales'. -Condado Be Bristol
-Condada de Middlesex 03901,O3gO2,03903,03904,03905,03906 -Condado de Kent
-Condado de Norfolk 03907,03908.03909,04001,04002,04005 -Condado Be Newport
-Condado de PI mouth 04072,04073,04083,04083,04090,04064
93 -Condado Be Providence
Y 040R,e Saga ahoc n Its siguentes
04093
-Condado de Suffolk -Conda de Sagadahoc en Its siguentes codigos postales: -Condado de Washington
-Condado de Worcester 0104086,04287r 04530,04548 • •.i-
04562,04579
'Los desechos de jar?n no se aceptan an todas as areas.Visite-tbebagster com a III all-877-789-2247 para obtener mas Ihormaci6o."d seroicio de recolec ion
es preparescado por una subsniaria de,Waste Management.Inc que France localmente.La balsa de Bagrter as propomionado per WM Bag va LLC no sampan waste
Management.Bagster'.Dumpster in a Bag'y BIN FILL.GONE®son marces regi tradas de Wel 31 Lee.
104,105,106,111,198-v10.11
CITY OF S.lL&Nfs Akss.ICF-HUSETTS
uLtl.n�vc DEP.1R"I1tE\T
I'O �X!.1iHCVGTON STXMM- , 1*0 FLOOR
rRL (978) 143.9599
K)JtHERL&Y OUXOLL R�x(9la) J�49&4d
MAYOR Mam. SST.Pmufi
DrR=Cfl OP PLBLIC PROPIRTY/8l'Q ma CO301IS1tOV Ell
Constructloa Debris Disposal Atfidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building.Coder 130 CMR section 11 I'J
Debris. and the provisions of WOL a 401 S 349
Building Permit At is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed wrote disposal facility as defined by NICL o
111, S 130A.
The debris will be transported by:
(n.une act haulu)
The debris will be disposed of in
u rr
�L q ym—elof •I:1 IIY)(name or today)
/Y.O ��hOYCL�'lOY1
,�-
055_!_b.11L Mo C,e S
IJdreff of r�riLiy) —
,jrNfu of e i pphcanf
` �JfO
� o Y
CITY OF S.U-F.Nf
PUBLIC PROPERTY
DEPART1tENT
N,�wa t�e w.�w,-,or.stress•l,u�y VwsWow�srn otro
ni.9-&?wstt rtz 97s.7169ay
HOMEOWNER LICE.YSE EXEMH MOIN
Please Met
Date Z/-L1 l
Job Locadon '24 \)a,\\Pu 3- 1
Home Owner Address alLk S*.
Home Owner Telepboee I-97 sr - 7,V 4 -7 9 L.
Preeaot Mailing Address Su v n
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units Of teas and to allow such homeowners to engage an individual for
hire who.does not possess a licensed provided that the owner acts as supervise
DEFINMON OF HOMEOWNER
Penton(s) who owns a parcel of land on which halshe resides or intends to resider on
which there is, or is intended to bq 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
OQlcial, that hatshe 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 understands the City of Salem
Buildin` Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and
reegguiuir—ements. .
HOSdEOWNERS SIGNATURE
APPROVAL OF BUILDING NSPECTOR
See other side for state code