74 VALLEY ST - BUILDING INSPECTION The Commonwealth of Massachusetts
dd r. Board of Building Regulations and Standard CITY OF
Massachusetts State Building Code, JNQpNAL SERVIC gz SALEM
evi.ced Hlar 20/1
Building Pennit.Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwellin91114 MAY
This Section For Official Use O
Building Permit Number: D p '
s
Building Official(Print Name) nal Uate
SECTION 1: SITE I ORMATION
1.1 Proper y Address: �. 1.2 Assessors clap&r. Parcel Numbers
VA I Lee t s
I.la 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 Il) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (NI.G.L c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zome'?
Public❑ Private❑ Check ifyes❑ Municipal ❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Owner'of ecord: (�
6os l )SCE 5/-\L-e3A M � nlLl -7b
Name
I(P((hit city,
state,ZIP
^ p q
I U �r.-'c t..il� SA - g — O p�O (n
No.and Street "fclephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK (cheek all that apply)
Nov Construction ❑ Existing Building❑ Owner-Occupied V Repairs(s) "N�, Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed work': flf�/�i ,�' IA V fJ
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and iMatcrials
I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
'. Electrical $ ❑Standard City/I'own Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (IIVAC) $ List:
5. Mechanical (Fire $
Su ression Total All Fees:$
Check No. Check Amount: Cash Amount:_
6. Total Project Cost $ ❑ Paid in Full ❑Outstandino Balance Due;
817S°-
hti ( �
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
Qatl` License Number Expiration Date
••fn Y .
Namc of CSL Hod&fii t'` ` --
List CSL Type(see below) f
" �
_- 1" t All` 'Type Description
No.omd Street G i.i {1 -4 N3 �•,�. '•-s
U Unrestricted(Buildings up to 35,000 cu. R.
R Restricted 1&2 Family Dwelling
City/town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
IiIC Company Name or IiIC Registrant Name
No.and Strect Email address
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(NI.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 Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLAWILTION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contai in this applicatio ' true and accurate to the best of my knowledge and understanding.
P ' wner's or Authorized genlb Name(Electronic Signature) Date
NOTES:
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
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.nmss.eQv/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq. R.) (including garage, finished basemendattics,decks or porch)
Gross living area(sq. R.) 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"
CITY OF SALEM, MASSACHUSETTS
BUILDING DEPARTMENT
120 WASHNGTON STREET,31iD FLOOR
h �rrn, TEL. (978) 745-9595
FAX(978) 740-9846
KIMBERLEY DRISCOLL
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date 05- Zz L4 \
lob Location 7 L/ V ALLga�
Home Owner Address IsA-11Q(�
Present Mailing Address S_s
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
APPROVAL OF BUILDING INSPECTOR
J
-'� Cin of S: LEI [, E-ITS
1 BULLOLNG DEP.IR-MIUiT
120 WASHNGTON STREET, 1 FLOOR
.v ham, T SL, (978) 745-9595
RM<(978) 7-10-9843
!US[BE1tLEY DRISCOLL
NL4Y011 TI-101LAS ST.PIERM
DIRECTOR OF PGBLiC PROP ERTY/8CII.DLN(;CONNISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CAtR section 1 l L5
Debris, mid the provisions of INIGL c 40, S 54;
Building Permit M 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 e
t 11, S 150A.
The debris will be transported by:
y
(name of hauler) "1
The debris will be disposed of in
_ (nantC of facility)
(address of tileility)
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