16 VERDON ST - BUILDING INSPECTION (2) \� The Cumnionwcaith of Massachuscits
f Board of Budding Regulations and Standards *018"wwo
t� Massachusetts Stan Building Cale, 78f)CMR, 1'"edition
n� Budding Permit Application To Construct. Repair. Renovate Or Demolish a
One- or Tuu-Funuls Duelling
This Secuo F r Official Use Only
Building Permit Number: D`e ppl
Signature: t-1,9 4_ Mu
Budding Commissioner/ Inspector of Btuldm I if Due
SECTION 1. SITE INFORMATION
1.1 Progeyty.}Qdre d� (-' e/ 1.2 Assessors Map& Parcel Numbers
1.1 a Is this an(aaccce led street''yes 6-'no Map Number Parcel Number
1.3 Zoning Information: IA Property Dimensions:
Zoning District Proposed Use Lot Area(sq A) Frontage(A)
1.3 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40.154) 1.7 Flood Zone Information: 1.8 Sewnge Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal s stem O
Public O Private O Check if sI3 Y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of cord:
P(/es4�u e
Name(Print) Address for Service:
Signatur Telephone
SECTION l: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction O Existing Building O Owner•Occupied O Repairs(s) O 1 Alteration(s) O Addition O
Demolition O Accessory Bldg. El I Number of Units_ Other O Specify:
Brief Description of Proposed Work':
`- +7 5
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: I 011leld Use Only
Item Labor and Materials
I. Building s 1. Building Permit Fee: li a Tntlicate how fee is determined:
O Standard CiryrTown Application Fee
2 Electrical f O Total Project Cost'(Item 6)x multiplier x
) Plumbing f 2. Other Fees: s
a. Mechanical IHVAC) $ List:
s %fechanical 1Fire s Total All Fees: S
SU re"SIOn
Check No. _Check Amount: Cash Amount:_
6 Total Project Cost: s 0 Paid In Full 0 Ouwandmg Balance Due:
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SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Constructlon Supervisor(CSL)
" License Number Espumion Date
Nyae of CSL Helder List CSL Type(,cc tic-low)
a
r�oe I Descn non
Address
U I Unrestricted(up to 33,000 Cu. Ft.
R Restricted IA2 Family Dwellin
Signature M Masonry Only
RC Residemial Roofing Covering
Telephone I wS IResidential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e. 1l2.1 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.......... O 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 ill
S 7b WNER'OR AUTHORIZED AGENT DECLARATION
I• as Owner or Authorized Agent hereby declare
that the statemen m ormation on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
Si ned under the eams and penalties ofperjury)
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 have access to the arbitration
r
rogram or guaranty fund under M.G.L. c. 1 J2A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR.Regulations 110 R6 and 110.RS, respectively.
When substantial work is planned,provide the information below:
floors area(Sq. FL) (including garage, finished basement/anics.decks or porch)
living area(Sq. Ft.) Habitable room count
er of fireplaces Number of bedrooms
er of bathrooms Number of halfbaths
of heating system Number of deckv porches
of cooling system Enclosed Open
3 'Total Project Square Footage" may he suhstituted for 'Total Proicci Cost"
CITY OF SM-E.IM
PUBLIC PROPERTY
DEPARTMENT
%"u.u� cur•
Vwwe i]tivrmuMc+n+Ynrsr*sUSatNUMAOMFMoWo
nu rs-745-9s"•F%x+-f7+a9e4
HOMEOWNER LICENSE EXE.M"10N
Pigs" Mal
Date
Job Location--ZL2 �P •� _ J '�i�r �l�
Home owner Address
Homo Owner Telephone
presme Mailing Address
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or leas and to allow such homeowner@ to engage an individual for
hire who.dos not possess a license.provided that the owner acts as supervisor.
DEFINMON OF Hob=WNER
penon(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 dwelling6 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"shag submit to the Building Of Icial,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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
ill comply with said procedures and require ants,
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING NSPECTOR �
See other side for state code
.y
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
NI U,nt 120\X'.%Q1J\l.;0N 51'1(LfT TO SA r\t,
Trl:978.745-9+95 ♦ FAX:978J449846
Construction Debris Disposal Affidavit
(required fur all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section It 1.5
Debris and the provisions of MGL c 40, S 54;
Building Permit f#
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
t 11. S 150A.
debris will be
The deb transported by:
(name of hauler)
The debris will be disposed of in
(name of faa 1ty)
(address of facility)
l
mgli ore of permit applicant
date
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