50 VALLEY ST - BUILDING INSPECTION (4) A
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The Commonwealth of Massachusetts
} Board of Building Regulations and Standards CITY
t; !`y ) Massachusetts State Building Code, 780 CMR, 7"edition OF SALF.M
"' 41' Revised Juntsur v
Building Permit Application To Construct,Repair, Renovate Or Demolish a 1. zooa
One-or Two-Family Dwelling
This Section For Official Use Only
( Building Permit Number' + Date Applied: L O
Signature: (fX 1-1 zIld2/ �
\`^ Building Commissioner/46spector of Buildings Date
^\ J) SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
I.1 a 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 It) Frontage(R)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Require) Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private O Check if ycsCJ Municipal❑ On site disposal system ❑
SECTION 2: PROPER Y OWNERSHIP'
Owner of Record:
p NP, ,ViIA 5� �A �A 5 T
N e int) Address 'Service:
ne
azure Te epho
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building 3- Owner-Occupied M— Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief ript'on of Proposed Work'': S - IM •S -+— `�
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard CityfTown Application Fee
❑Total Project Cost(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
Fa. Mechanical (NVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S `�j4-14 ❑Paid in Full 13 Outstanding Balance Due:
a
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL-I lolder list CSL'rype(xe below)
r. lion
Address U Unrestricted u to Cu.Ft.
R RerSolid
anvil Dwellin
Signature M M
RC Ref C'overin
relephone WS RendowandSidin
SF Reid Fuel Bumin A liance InstallationD Remolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address / Expirat' ate
Signature relephonc
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.4 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...........O
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.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1 ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
*behalf. wne or Authorized Agenthe sins and nallies of 'u
NOTES:
I. 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 gA have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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
J. "Total Project Square Footage"may be substituted for-Total Project Cost"
CITY OF S.U.E.NI
PUBLIC PROPERTY
DEPARTIAENT
Rl1Ok/liY ryw•n
WY'O� 130 WA2W*Gr M 9mw•SAUK%&.9AG4LSWM 019'e
71J_974Ni9S9S•F.aL 93-746964
HOMEOWNER LICENSE EXEMMON
Plum h/ I
Dab
Job Location �O V,41 I aL-L
Home Owner Address w ? V
Home Owner Telephone
Present Mailing Address La-
no 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 who.does not possess a licens%provided that the owner acts as supervisor.
DERNMON OF HOMEOWNER
Persons) who owns a parcel of hose/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 Otticiak 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 tha=Ah�
of Salem
Building Department minimum inspection pand that she
will comply with said procedures and requir
HOMEOWNERS SiGNATL'RE
67
,APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SALEM
• PUBLIC PROPRERTY
DEPARTMENT
.I'.1P M111 'Mly+'•1I
\I .+"x I iC\�••\d ll\b:,+V 51'Ntry *$.111 fl.St.Ni.\r 111 V I
Trl: 971J41946
Construction Debris Disposal Af ldavit
(required fur 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 At is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11. S 150A.
Th debri will b transporcd by:
1 norm of hauler)
The debris will be disposed of in
(n one of aci Ity
(Adm..of Iacdayl
signature ofpermit applicanh
CJ
date