78 VALLEY ST - BUILDING INSPECTION (2) Q7/24/2009 09: 48 9787409846 CITYOF SALEM PAGE 01/04
f a The Commonwealth of Massachusetts Town of
' [ Board of Building Regulations and Standards
Massachusetts State Budding Code, 790 CMR. T"edition Budding Dept
I(/ Building Permit Application To Construct, Repair. Renovate Or Demolish a
one.or Tsvu•Furmli,Du•cffing
This Section For Official Use Only
Building Permit Num r: Date Applied: fit O
Signature:
7' `
p
Bmldfng Corrtmisstaner/Inspector of Buildings Date
SECT[ON 1:SITE INFORMATION
1.1 Pro rt A rest S� 1.2 Assessors Map R Pared Numbers
1.1 a Is this m acce ed strece?yes no Map Number Parcel Number
1-3 Zoning Information: IA Property Dimensions:
Zoning Disinct Proposed Use [.a Awn 154 Rl Frontage(n)
1.5 Building Setback$(0)
From Yard Side Yards Rem Yard
Required provided Required Provided Required Provided
1.6 Water Supply:(M.O.L c.ao,I31) 1.7 Gland Zone Information: 1.g sewage Disposal System:
Publfc❑ Private O Zone' — Outside Flood Zone? Municipal O On site disposal system O
Check ityeso
r SECTION 7: PROPERTY OWNERSHIP'
2.1 Qta(tteOr'a, f RSm S. Z -I n.% Alasm456XCAZ�
Nam 0 Addreiin For Service: G,t,
1TLit.
91 OWN Telephone
SECTION J. DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction Existing Building Owner-Occupied Repsirs(s) ❑ 1 Alteration(s) ❑ Addition O
Demolilion _ I Other ❑ Spec*:
Brief Description of proposed Work,:
t .nXAst Qasx, .ts t of
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Isom Estimated Costs: OQklal Use Only
Labor and Materials
I, Budding f I. Building Permit Fee: S Indicate how fee jd
❑Standard Ciry/Town Application Fee
2 Electrical f ❑Total Project Coal'(Item 6)x multiplier I Plumbinga. .Mechanical (HVACI5 Mechanical (Fire S Tatal All Fees: f
Su reatiOnCheck No. _Check Amount: Cash Am
r, Total Project Cost: f ❑Paid in Full 13 Outstanding Balance Out:
.07/24/2009 09: 48 9787409846 CITYOF SALEM PAGE 02/04
SECTION S. CONSTRUCTION SERVICES
5.1 Lieeosrd Consrruetlon Supers isoe(CSLI ,
•• Lwegae Number Etpirauon Dale
Nyx ar CSL- ItylJer Livt CSL Type1»�(pwI
a T Description
Aihhrsa U Unrestncted a to 73.000 Cu Ft.
R Resaicred Id2 FamilyD+Clllnit
�ryrunire % Mason Only
RC Residentral Roofin overing
Telephone I WS IResrdennal WTnJow and Srdm
SF Residentul Solid Fuel Burnie Appliance Installation
D ResTTknI Demolition
=A=ddmu
vement Contractor(HIC)
aistram Name F�:' gisvauon Numbs
Eapirarion Dote
Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. I57.0 25CM)
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...........l7
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 matte
relative to work authorized by this building permit application.
si to of Owner faro
SECT�ION`^7bb!OWNERi OR AUTHORIZED AGENT DECLARATION
I. �O�DGf`� { 41\ ,as Owner or Authorized Agent hereby declare
that the statements and information an the foregoing application are true and accurate,to the beat of my knowledge and
behal e _ J
qo
Print Name
SignmasofOwner or Authorized Again Dan
Si under the ins;and penalties ofperiuryL
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(trot registered in the Home improvement Con(raclor(HIC)Program),will egg 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 round in 780 CMR Regulations I IO.R6 and I IO.R3,respectively.
2. When substantial work is tanned,provide The mforination below;
Total Roars area(Sq. Ft.) IAA _ (including garage,finished basement/atlics,Jerks or porch)
Gross living arts(Sq. Fr 1 Habitable room count
.'umber of fireplaets Number of bedrooms
Number of bathrooms Number of halribaths
Tvpe of heaving system Number of Jecksi porches
Typeorcoobngsystem Enclo%cd Open
3 "Total Project Square Footage may he uhslrtuted ror"Total Proiccl Cost'
0.7/24/2009 09:48 9787409846 CITYOF SALEM PAGE 03/04
CITY OF SM.El%t
PUBLIC PROPERTY
DEPARVUENT
iu,uratsr..� ..
7tr.r,a.746.9"S• FAx 911-trb96A
HOMEOWNER LICENSE EXEMPTION
Plesse P 02
Job Location �g
Home Owoes Address
Home Owns Telephone
Premaf MoilkS Address
The current exemption of"Homeowners^was extended m include owner-occupied
dwellings of two Units or lore and to allow such homeowners to engage an individual for
hire who,dos not possess a licenser provided that the owner sets as supervisor.
DBFDaMN OF HONMOWNER
Person(s)who owns a parcel of land on which he/she redder or intends to reside. on
which there is, or is intended to be,a we or two &milt'dwellin& attached or detached
structures accessory to such use anNot.farm anwtu nm 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 Oflleiat on a forth accWtablo to the Building
OSlciaL that he/she be responsible for all such work performed wader 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATL'RERj
APPROVAL OF BUILDING INSPECTOR
See other side for state code
07/24/2009 09:48 9787409846 CITYOF SALEM PAGE 04/04
: � .
CITY OF SALEM
1g ' ; Pt'i3LlC PRi)PRERTY
DEPAIt"I'NIENT
'.I .. . i �.. N .r C'. . '.1. Ir ( • \1r111. \I l. l .I'r .
t I I 4';1 '1: rY•ri � t \C '!-.{ 'J; •r\Jr.
Construction Debris Disposal Aftadas it
(realuind litr all demolition and mnurauun work)
In accurd:►ncc w lth IhJ. ninth odition of the State Building Code, 730 CA112 sectnnt 11
1
Debris,and the provisions ul'N1GL c 41). S 54;
Building Permit H is issued with fhe condition that the debris resulting from
w shall he di.ioscd ut in a pruperly licensed waste disposul facility as defined by NIGL c
this work l
111. S 150A.
The debris will he transported by:
In J:..1'hauler►
I he dchris will be disposed uf'in
{namr al lacl Ily)
•icnalwC irf pelnut.gydlunt
g-fi {- vq