38 WALTER ST - BUILDING INSPECTION (2) � ZS — � �� Z `� "s° ZS`t
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State um�)'
Building Code, 780 CMR SALEM
Revixed,blur 10/1
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Fnrnily Divelling
This Section For Official Use Only
Building Permit Number: I Date Ap ied: O
Building Otlicial(Print Name). - Signature- - Date
SECTION 1:SITE INFORMATION
LI PropeRrtyA 5�` L2 Assessors iNap 3r Parcel Numbers
1.la Is this an accepted street?yes [P no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sy 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply;(M.O.L e.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Publicx Private❑ Zone: — Outside Flood one? Municipal�On site disposal system ❑
Check if ye
SECTION 2: PROPERTY 01 NERSHIPI
2 Ownerl of Record II'' j
��ar y�sir„r G + P.0 !YA i Cr ! 'a6m 019'20
tN4111e(Print) —� City,State,ZIP
$ ro? �lS G�
No.and Street � Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed�V rk-:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building S co I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cose(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: $
4. Mechanical (FIVAC) S List:
5. .Mechanical (Fire ��/ A
Suppression) So 'foCd All Fees:S
Check No._Check Amount: Cash Amount:_
6. Total Project Cost: S �Op 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL"Type(see below)
No.and Street Type - Description -
U Unrestricted(Buildings tip to 35,000 cu. It.)
R Restricted 1&2 Family Dwelling
City/fown,State,ZIP ib1 IMasonry
RC Roofing Covering
WS Window and 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 Dale
HIC Company Name or HIC Registrant Name -
No.and Street Email address
City/Town, State,ZIP fete hone
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...........❑
SECTION7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN:
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT"
1,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date J
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
col rain d in tI 711icafion is true and accurate to the best of my knowledge and understanding.
6Aw 0 IZ
Prir�i % Ps or A u orized 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 I.G.L.c. I42A.Other important information on the HIC Program can be found at
www.nwss.gov'ocr1 Information on the Construction Supervisor License can be found at wwtr.mass.covldns
�. When substantial work is planned,provide the information below:
Total floor area(sq. 11.) (including garage, finished basement/attics,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 or 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 SA LEM
PUBLIC PROPERTY
DEPARTI%MNT
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HOMEOWNER LICLNSB Ext.m"I01*4
PW" Print
Data
lob Loaadao �4 Sfi m 0l 70
Home Owner Addrearr
Hoe»Owner Telophoee r y
Preled Mailing Address
The currenta stempdna o!"Homeowners"was atessded to imiude owner ocsupt ed
dweUings ottwo Units or few And to Allow such homoowoas to
him who doe not peewee a Ue:Aaser provided that the owner act@ a@ P,{�vidu JI for
OFYINMON 0/HOMHORMB$
Perwn(s) who owns a pared olLod on which WAS raidea or intardr to resider on
which there it. or is intended to ber a one or two ILmily dweUing; atachad or datuhed atrucnues uexswry to such use andr'or rum Rtnsaturee. A pawn who constructs more
than arse home in a two year period.shell not be considered a homeowner. Such
"homeowner"shall submit to the Building OQlci&k on a form scceptable to the Building
Oillcisl, than he/Rhe be responsible for All Ruch worst performed under the Bmldtng
Permit
The undersigtud "homeowner's Asswnea reRponsibility for complinxe with the State
Building Code And other applicable by4sw1 use repulsdonS.
The undenigned ^homeowner cer Iles tha helshe undentsnds the City of Salem
8WIdint OepArtme•nt minimum inspection procedures and requirements and that het/she
.viIt comply with said proeodura and r rem
HOtiMA HERS SIG.NA TLRB
.APPROVAL OF 3U/LDI`!G I`r'SPECTOR
See other lido for swo code
i CITY OF S.U1 E.Nl, UxsSACHUSETTS
BL'1 =\,G DEPARTl.I&NT
N 130 WASHNGTON STREET, 3}'FLOOR
TEL (978) 745-9595
FAA.(978) 740-9846
KwBERL.EY DRISCOLL
, LiYOR THo.%wST.PtERRE
DIRECTOR OF PUBLIC PROPERTY/B1:1 -DNG CONWISSIONER
Construction Debris Disposal Affidavit
(required for 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# 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 debri will be transported by:
(name of hauler)
The debris will be disposed of in
(nami of facility)
(address of facility)
i
signature of permit applicant
date
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