51 VALLEY ST - BUILDING INSPECTION (5) 035`I`� S
The Commonwealth of Massachusetts ,
Board of Building Regulations and Standards
Massachusetts State Building Code,780 CMR Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolis101i JUL 25 A
One-or Two-Family Dwelling
T!€ys Section, tat ci+d; e
Building Pwmk Ni sibe , Date Ap
)Yuilding0#�eiat(Priutt�iame) - �.. Stgoaaae -' /� /�
$I$CTT 11:$TfEINFOB!"'ITi3W
t 1.1 Property A ass: 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted street?yes t no Map Number Parcel Number
L— 1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq fl) 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:
Zone: Outside Flood Zone? Municipal❑ On site disposal system ❑
Public- Private❑ — Check if yes❑ _
SECTION 2: PROPERTY O�ITiERSH19't
2.1 Owner'of Record:Z Q
'f'i/n Ot t��l�'� LlL—
Name(Print),� nyvn �'J /City,State,ZIP
I Kft
Telephone ail Address �-
No.and Street
SECTION 3-HESCRIP'TION OF PROPOSED WORI{s(check all that apply)
New Construction❑ 1 Existing Building❑ L=0wjner-;0c=cjup:ied ❑ Repairs(s) O Alteration(s) ❑Demolition ❑ Accessory Bldg.❑ _ Other ❑ Specify:
Brief Description of Propos I
Work=:
L
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: OfSeial Use Only
Item ab and or Materials
1.Building $ �Q 0D 1. Building Permlt Pge;$ Indicate how fee is detormined
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item6)x multiplier - x
3.Plumbing $ 2. Other Fees: S r
4.Mechanical (HVAC) $ List' .
5.Mechanical (Fire $ Total All Fees:$
Suppression)
'-7 check No. Check Amount: Cask Amount:_
6.Total Project Cost: $ �Q, ❑Paid in pall. D Outstanzi Balance Due:
TO O fZ .
SECTION 5: CoNE7'RoMON.SIiaVI4 S
rCoistrucfl4aioa Supervisor License(CSL)
License Number Expiration Date
lder
3u:. ,; -'} List CSL Type(see below)
TYPe :Daswtptroa_
U I Unrestricted(Buildings to 35 000 cu.R
R I Restricted l&2 FamilyDwelling
City/Town,State,ZIP I M I Masonry
RC I Roofing Covering
WS Window mod Siding
SF Solid Fuel Burning Appliances
I I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
Ci /Town State ZIP Tel hone
SEC MN rjt WORKERS''COAUTMATION 24FORANCE AFFHIANU(ALG.L.c.152.§ 2-1qQ6))
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 .......... O No...........❑
SEiCTIOPi jai OWNFat AU THORIZA T6 8E COII4PLETEA WRE1V
OWN$R'S AGENT QA O CTOR AF IIVG PERK
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 Owner's Name(Electronic Signature) Date
SECTIO14 7h: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
contained in this Ilea to the best of my knowledge and understanding.
Print Owner's or c Signature) �.. ..D e l6 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
w�vw.mass.eov,'oca Information on the Construction Supervisor License can be found at wwwmm&ggi/
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"
° QTYOF SALEM, MASSACHUSETTS
` BUILDING DEPARTMENT`
\„ 120 WASHNGTON STRE E T,3" FLOOR
\ TEL. (978)745-9595
KIMBERLEYDRISCOLL FAX(978)740-9846
MAYOR THOMAS ST.PtERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CDAWSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT.
lG
Date �
Job Location U �(!�L'�Gf gz"A� OT ®l
Home Owner Address__ U �//�����!✓
Present Mailing Address �CYivu
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= r o two-family dwelling, attached or detached structures accessory to such use
and/or farm structures. A person who construc
ts cts 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