45 VALLEY ST - BUILDING INSPECTION I'he CbmnnonsvcalIh of ill:usachuscl is
hoard of 13uihling Regulations and Standards CI'VY OF
'r �1;asachusctts State Building Code. M CNIR SALIi\1
11jildiog Permit Application To Construct, Repair, Renovate Or Delnulish
One- or Tuv-Piwnh• Di e in,\r
This Seetion For Official Use Onl
Building Permit Number. _— D to Applied:
Budding ORictal(Print Nmne) Signa ure D.to
SECTION 1:SITE INFORMATI
1.1 Property Address: 1.2 Assessurs,MAto dt Parcel Numbers
I.la Is this an acre led street? es no Map Nunnlser I'orcel Nwnhcr
I.! 2oning Information.- 1.4 Property Dimensions:
Coning District Proposed Uw Lot Area(sy II) Frontage(II)
1.5 Building Setbacks(it)
Frunt Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1.c.J0.§SJ) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ zone: _ Outside Flood Zone?
Check.. es❑ Municipsl❑ On site disposal s)stem ❑
SECTION): PROPERTY OWNERSHIP'
2.1 Owners of Record:
N;wse 11'nnl \� � s03 W\n ryA O)C O
q7� goo
No.:mJ Sim-etrelephuna hmurl A dmsf
SECTION!: DESCRIPTION OF PROPOSED WORK'(check all that apply)
Now Construction O Existing Building❑ Osvner•Occupied ❑ Repa(rsls► ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ .Specify:
Brief Description of Proposed Work': b t
SECTION a: ESTIMATED CONSTRUCTION COSTS
hens Estimated Costs:
ILahor and.\Iatoriah) Official Use Only
1. Building S I. Building permit Fee: S Indicate how tot is determined:
'. Iflcarical S ❑Standard City+Tosvn Application Fee
t I'lumhing S ❑Total Project Cost'(Item 6)x multiplier _._— x
1. Usher Fres: S -
J, \Iah.wic.il III1 \(': S Lis::
S❑ +nessioni S rota! .\11 Fees: S
)'mal Project Cost: S (Dao ( ('heck No. ('heck:\nunwt: .
❑P.lid in Full 0 Oulstwiding Bal.wce Due:
SECTIONS:
P,
I coise Numhe r F\piralioli Mile
Name lil't.SI I ist 0 PC jiec IwItm
"I %
I)civriplion
191!
NIL "Id rM it
..;Ill000
It 14ctrioed 1&1 1
%I NIamill
TI I RC Ittitifill cil%vrin
window Uld"lull
SF .4olid Fuel Burning Appliances
I IllSkIIU!!!!a1'de bona
----------
�l
D IRMOI lion
5.2 Registered Home Improvement Contractor(1119L)
FI—IC C,linpio) Name tir I IIC Registrant Name
l:muil address
No. 'ind S eoll
reic one
City/Town,State ZIP ION INSURANCE AFFIDAVIT(MtG.L C. 152- 2SC(6))
SECTION 62 ed with this application. Failure to Provide
Workers Compensation Insurance affidavit must be completed and submitted
this affidavit will result in the denial of the issuance of the building permit.
Signed A Mdavit Attached? Yes ..........a No...........El
SECTION 71: OWNER AUTHORIZATION TO BE C
0111PLETED 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.
Date
Print pwncr's Nwnc(Electronic: ;: —
ignuturc)
_Cifrown�.Slitt- ZI
h
L I I 10.
WORKERS'COMPENSATION
I
SECTION 7b: OWNER OR AUTHORIZED AGENT DECLARATION
By entering my name below. I hereby attest under the pains and penalties of perjury that all of the information
Cont ' ed in this application is true and accurate to the best of my knowledge and understanding.
DUIQ
N 4n rFSoTES:.
I. An Ownerwho obtains a building permit to do i7is,her own work,aranowner who hires an(oot registered in the Home the arbitration
Improvement Contractor(HIC) Program),will no have access to
0 can be round at
program or guaranly fund ulider.M.G.L.c. 14-I.N. Other important information on the HIC Program
i Itrormation on the Construction Supervisor License can be round at
lien substantial work is planned, provide the in furmatiun below:
rotal floor area(iq. t) I I including garage. 1*11lishcd basement attics. dv%;ki or porch)
Habitable rouni count
Groii fi\ilig area 154- It I Nillilher o(bvdrowits
till IM or fircilinces
porJics
Ile of 11c.1ting s)SIVIII .01'ell
1*\J,coft:oolillg i.%itoll
MaN Ie Itibstititict! Illr Project Co%I
CITY OF S.u.E.til
PUBLIC PROPERTY
DEPART.N[ENT
u.ar.asr o.nnu
MAVOe t la 7womatd buff•lAan4 NAnAoa srm of$V
M 9-&715.95"• t+.ut.93.746.964
HOMEOWNER LICE.YSB EXE.M"104(
Plew "I
Date 6915Ila
Job L«ados �1S�o Ue� S� S 0-� fri) oR-)0
Home Owner Address
Home Owner Telephone q-70o Q S 0 -? 70
Prssaot Mailing Address I,-
The current exempdon of"Homeowners"was extended to include owner-occupied
dwellings of two Unite or leas and to allow such homeowners to aigsgs an individual for
hire who does not possess a"eerie,provided that the owner sets as.supervisor.
DEFINMON OF HOMEOWNER
Persons) who owns a pared of fand on which ha/she red"or intende to resider on
which then 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 OQlci4 an a form acceptable to the Building
Official, that hdshe be responsible for all such wort performed under the Building
Pantit
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
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATL
.APPROVAL OF SUILDNG NSPECTOR
Sce other side far state code
TA
CITY OF S.1c.E,Nr, A1SS.ICH(.'SETTS
f3l'tLOLVG DEi.1ATTlE.\T
I'O 17.1iHGVGTON StusT, JW FLOOA
• ••. 1�L 1978) 74S•9S9!
KIMBERLSY OUWOLL P.Vt(973) 11Q984
.MAYOR MONWST.PM ■.
D(Ascrox OPPLSLIC PROP!RTY/gt::MnLNr, CO.%O,,S,OVER
Construction Debris DISPOS31 Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 C.NR section I I I.J
Debris, and the provisions of MQL o 40, S 54;
Building Permit Ai isissued with the condition that the debris resulting from
INS work shall be disposed of in a pro
111, S IJOA. Petty licensed waste disposal facility as defined by AICL c
The debris will be transported by:
(name of hautar)
The debris wi II be disposed of in :
r,da.n, or•n,d,,yl
' of permit i iUnf
:pia