46 VALLEY ST - BUILDING INSPECTION (2) Checommonwealth ofMassachusetts RECEIV .D
INSPECTIONAL 3ER'clrvgF
Board of Building Regulations and Standards SALEM
,,/� Massachusetts State Building Code, 780 CMR 7�pp LLSSt}ov � e ed llur 2011
W Building Permit Application To Construct, Repair, Renovate t7t Dtt�
-or Tivo-Family^ 1 One l y Dwelling
lv This Section For Official Use only
Building Permit Number: Date.Applied:
I� I D to
al(Print N
building Official Signature -
I SECTION 1;SITE INFORAIATION
Ij oper_ty Address: - 1.2 Assessors Map&Parcel Numbers
ll � 1- L L �- SqL J M .O/ - -
I.1 a Is this an accepted street9 yes_ no: Mop Nwnber Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District ,. -Proposed Use - Lot Arco(sq it) - Frontage(11) -
1.5 Building Setbacks(It)
Front Yard - - Side Yards Rear am
Req=.d Provided Required -Provided. . Requited Provided
1.6 Water Supply:(M.G.L c.40.§54) 1.E7 Flood Zone Information: 1.8 Sewage Disposal System: '
Zone; _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public O Private❑ Check 1f es❑
SECTION PROPERTY OWNERSHIP'
?Iwnertof Record:LWEA/ r(,rN60L. s,rJL /, JV1if . 6Print) City.Sla[e,ZIPlifut/ fir 9 76'- 7VV S&-4l G�/�Q cr�c++TT Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply);
New Construction❑ Existing Building❑ Owner•Occopied ❑ Repairs(s) ❑ Alteration(s) O Addition ❑
Demolition O Accessory Bldg.❑ Number of Units_ Other O Specify:
—�� Brief Description of Proposed Work-: Kn
S'Ivt-tP R�- RoaF
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials) %
I. Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ p Total Project Cost'(item 6)x multiplier x
3.Plumbing S 21i pther Fees: S
4.Mechanical (EIVAC) S List:
5.1%leehmticaI (Fire S Total All Fees:S
Stippressiun)
Check No._Check Amount: Cash Amount:_
dDotal Project Cust: S a S�j_ �O Paid in Full ❑Outstanding Balance Due:
gnat �-•� I 1 ��
SECTION 5: CONSTRUCTION SERVICES
5.1 Cosrstruction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder List CSL'rype(see below)
Typc - Description .
No.and Street e
U Unrestric ut ings up to 35,000 cu. 1l.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M 'Masonry
RC Roolina Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I I Insulation
Telephone Email address D Demolition
5.2 Registered home Improvement Contractor(HIC)
111C Registration Number Expiration Date
IIIC Company Name or HIC Registrant Name
No.mid Street - Email address
Cit /Town State ZIP Tele home
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L:r.152.§ 25C(6)y
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Isivance of the building permit.
Signed Affidavit Attached? Yes..........O No........... O
SECTION 7a=ERAUTHORIZATION:TOBE.COMPLETEDWHEN .,.
OWNER'SAGENTO tCONTRACTOR APPLIES FOR BUILDING PERb1IT'
1,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 71b: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
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorize)r\gene's Nmne(Ekctronie Signal e) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
_knot registered in the Home Improvement Contractor(HIC)Program),will no have access to the arbitration
prugram or guaranty fund under 1v1 L. I.G. i Othcr Important tnformation on the HIC-Program can be found at
www m:us.eov'oca information on the Construction Supervisor License can be found at www.nms�
2. When substantial work is planned,provide the information below:
'rota) floor area(sq. ft.) 4 ,(including garage,finished basement/attics,decks or porch)
Gross living area(sq. a.) 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 ofcooling system Enclosed Open
3. "Total Project Square Footage"may be substituted i'or"Total Project Cost"
aQTY OF SALEM, MASSACHUSETTSBUILDING DEPARTMENT120 WASFENGTONSTREET,3" FLooR
TEL. (978)745-9595
FAX(978)740-9846
KIMBERI-EY DRISCOI_i,
MAYOR THOIVIAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONNUSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date //- .tit - l 5
Job Location 46 f/Az cW :5,
Home Owner Address #6 ✓q tG,-Y S7.
Present Mailing Address +s 486Yz;�,
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---`-? C
APPROVAL OF BUILDING INSPECTOR
GTY OF SALEA A ASSACHIBEM
BtA m cDBPAmmEw
120 WASIECIENSTRRET,3"ROM
UL(978)745.9593,
PAX(978)740-9846
BIMBERLEYDRISODLL
MAYOR 71KXW ST.P EM
DntEcrcotcFp=cpjta;ERn/BuiiDnccamumomR
Construction Debris Disposa/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 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:
V4
(name of hauler)
The debris will be disposed of in:
(name of facility)
-5 cc w C)
0
(address of facility)
Signature of applicant
Date
Tile C'ornrtzonwealaz of Massachmsetts
Department ofindrestrfalAccidents
1 Congress Street,Suite 100
BOston,M4 02114 20I7
www mass gov/dfa
wrkers'Compensation insurance Affidavit:.Builders/Contractors/E[ectricians/Plumbers.
TO BE FILED WITH THE PERMITTENG AUTHORITY.
Applicant Information Please Print Le btv
Name(Business/Oiganizatio»tindividuap: i-'dan iC
I P, JeIIt?Jv�7 1c,Vigg e
Address: ,
City/State/Zip: Phone#: ? - ?u,ti _ $ [t,t s
Are you a employer?Check the appropriate boa
Tof project(required):
I, am a employenviW��employees(full and/or part-time).=
[7-y��New construction2.❑]am a sole pmprielor or partnership and have no employees working forme in om•capacity-[No workers'comp.insurance required.] . Q Remodeling3.®1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t . ❑Demolition4.❑tam a homeowner and rill be hiring contractors to conduct all nark an m• ra e 1 Hill 0 0Building addition
SP PrYensure that all contractors either have workers'compensation insurance or are solei1. Electrical repairs or additions
proprietors with no employees. _
5.0I am a general contractor and I have hired the sub-contractors listed on the attached sheet- 12'❑Plumbing repairs or additions
These subcontractro have employees and have workers'comp.iasuraoc�.: 13.❑R500-repairs ,{
6.Q We are a corporation and its otimers have exercised their right of exemption per MGL c 14. Other'U!G1-1 e6(I?
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
-Any applicant that checks box 01 must also fill out the section below shooing their workers'compensation policy information"
r Homeovners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicatitine such.
,Contractors that check this box must attached an additional sheet shoving the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees they must provide Weir workers'comp"polity number.
I ant ana employer that is providing workers'con
irtforntatiou. tpetzration iasa;aacefor my enrplopees. Belolv is the policy and job site
Insurance Company Name:_ �Uv-ic n
Policy u or Self-ins.Lie.#:_ S-,{} ?Q /a
{ Expiration Date:( .3 76 l
Job Site Address: . Ll Ff � -ra rn —, S� City/State/Zip: Sa/er77 04
Attach a copy.of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under IYIGL c. 152,§25A is a criminal violation punishable by a fine up to S1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains and penalties ofpeK try that the iuforrnatian provided above is true and correct.
jr i nc/ t
Siettamre: -
iF;,�„- Date.,
Phone',7 1 7 Y14—R <I {
=Other
only. Do not write in this area,to be completed by city or totpu official.
n: Permit/License# -
hority(circle one):
health 2.Building Department 3.City/Town Cleric a-Electrical Inspector 5.Plumbing Inspector
son• Phone#: