65 VALLEY ST - BUILDING INSPECTION (3) The Commonwealth of Massachusetts CITY OF
i Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR SALEM
1 Building Permit Application To Construct, Repair, Renovate Or Demolish a 2evcscd Mar anu
One-or Two-Family Divelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Otlicial(Print Name) Signature
SECTION L SITE INFORMATION
x 1.1 P�pert AddT ess: 1.2 Assessors Ma & Parcel Numbers
p �KN SA p
I.I 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 Ili Frontage(11)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner t of Record:
TI i s �c�t-{
Name(Print) City.—State,ZIP 1
X S: yalVCk-J � on h
No.acid Street I 'relephone Email AJArcss
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ FExistmg Building`4 Owner-Occupied Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': lh
x
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: $
4. Mechanical (HVAC) S List:
i. ,Mechanical (Fire $ Total All Fees: $
Su ression)
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S ❑paid in Full ❑ Outstanding Balance Due:
/� T4lAt z6 ./J
r
SECTION 5: CONSTRUCTION SERVICFS
5.1 Construction Sun(C
nse Number E.cpimtion Date
Name of CSL Holder
C S L Type(see below)
No. and Streetype Description
U Unrestricted(Buildin�s ti to 35.000 cu. 11.)
R Restricted 1&2 Famil Dwellin
Cny/town.State,LIPM Mason
ry
C Rootin C'overinS Window and SidinF Solid Fuel Burning Appliances
I - Insulation
Telc honeU Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Ispiration Uatc
I IIC Company Name or I IIC Registrant NameNo. and Street
ddress
Ci /Town, State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 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........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,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 Owners Nmne(Electronic Signature) Date
SECTION 7b: OWNEW 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 application is true and accurate to the best of my knowledge and understanding. .
Print Owners or authorized Agent's Name(Electronic Signature) Date
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 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
oca Information on the Construction Supervisor License can be found at
2. When substantial work is planned,provide the information below:
Total Boor area(sq. ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. It) Habitable room count
Number of fireplaces Number of bedroorns
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"
CITY OF S.UY.Nf
PUBLIC PROPERTY
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HOMEOWNER LICENSB EXE.MMON
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Job Location (D
Home Omer Addteaa a
HomaOwnsr?elephooe "7 - 1
Prea d Mailing Addrew G
The tuned exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units air leg and to allow such homeowners to eagage an individual for
him who.does not posses a licaoso provided that the owner acts as supervisor.
DERNMON OP HOMEOWNEII
Pason(s)who owns a parcel of land os which hdsbe residee or Intande to redder, on
which there in, or is intended to b46 a one or two &mft dwelling,attached or detached
structurce accessory to such use and/or flan structures A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner'sW submit to the Building Omci4 on a form acceptable to the Building
Official, that hdshe 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 bylaws 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
vill comply with said procedures and requirements.
HONEOWYERS SIGNATURE
APPROVAL OF BUILDING ClSPE OR
See other side for state code
f'
CITY OF S.uy.%VI, �tiL-kSS.kCHUSETTS
Bl;I1DNG DEPARTMENT
130 W kskm4GTON STREET, Y'E200R
T M (978)745-959S
FAX(978) 740-9846
K!\C3ERLEY DRWOL L
MAYOR T HOmu ST.P[ERRS
DIRECTOR OP PCBUC PROPERTY/BCILDLNG COMMISSIONER
Construction Debris Disposal 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 c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit applicant
dat