41 WALTER ST - BUILDING INSPECTION The Commonwealth of Massachusetts
t i Board of Building Regulations and Standards l OR
Massachusetts State Building Code. 780 CMR. 7ib edition h1UV1`itiF\1 I 1
Building Permit Application To Construct, Repair. Renovate Or Demolish a Rr n �/.t. J,mmi,
r r
\ One- ur Tit Dti elling
This Section Fur se Only
Bwlding Permit Numbe . ,Dat p d: U S O t O
l Signature: �'a lgI0B
Budding Commissioned Id2pector ut Bwldin Dote
SECTION I: SITE INFORMATION
1.1 Property..�ddr : fe r S 1.2 Assessors Alup & Parcel Numbers
I la Is this an accepted street'?yes X nu_ Map Number Parcel Number
1.3 Zoning Inrormation: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage Uit
1.5 Building Setbacks(R)
Front Yard Side Yards Reza Yard
Required Provided Required Provided Require) Provided
1.6 Water Supply: (M.G.L c. 40. 4 54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public lal Private❑ Check if es❑ Municipal �On site Disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
t fir. N, t,aa. t4 , y i W e.l +cr s ►-
Name(Print) Address for Service:
978 7`/l 378y
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addiunn ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work : (g Z_ t a 10 CD ('ca n d ao d-
�Q. t
t'tark /"t✓S�� F. 1 i1e ..^E�� ^t- V $ 'he.� L
-78o c-�2 Also r� C.t- oFs� e . ,� �r asL� � ,, jk
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building $ 0. bo. r, L 1. Building Permit Fee: E Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ t r «� ❑Total Project Cost'(Item 6) x multiplier x
3. Plumbing S IWA 2. Other.Fees: S
4. Mechanical (HVAC) $ 'IVA List:
5. Mechanical (Fire g Total All Fees: S
Su ressiun)
Check No. Check Amount: Cash Amount:-
b. Total Project Cost: b y 000.00 0 paid in Full 0 Outstanding Balance Due
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Exptimum Date
Namc of CSL- Milder -1. '
Lisa CSL Type tsrr hclowl
T Dcscri lion
>ddress L Unrestricted lu to As.(W Cu. Ft l
R Restricted J&2 Fanul y D,%ellln
Signature N .Mason Onl
RC Residential Roulin Cosenn
Telephone N'S Resldenual Windu.I and Siding
SF Resvdenoal Sohd Fuel &tnuna
D Neidenual Demolition
5.2 Registered Ilome Improvement Contractor (HIC)
HIC Company Name or HIC Registrant Name Registration Number 9
Address Expiration Date
Signature Telephone J
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 pru.ide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... tJ 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
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I , as Owner or Authorized Agent hereby declare
that the statements and information 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
(Signed under the pains and penalties of perjury)
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregisterqcontraoor(not registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitprogram or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program anConswction Supervisor Licensing (CSL)can be found in 780 CMR Regulations 110.R6 and 1 10.R5, r2. When substantial work is planned, provide the information below:
Total floors area(Sq. Ft.) (including garage. finished basemenNatlics, decks
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms j
Number of bathrooms Number of halt/baths j
Type of heating system Number of decks/ porches
Type of cooling system Enclosed Open j
3. 'Total Project Square Footage" may be substituted for Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
120 W.V 111M,:ON S I RLIST ♦ SA I FM, MASSM IIL S] I is 0 19/-,
ri.:978-74i9) 95 + FAX:978-74&9846
Construction Debris Disposal Affidavit
(required ['or all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CNlR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit ft ---- is issued with the condition that the debris resulting from
this work shall be disposedof in a properly licensed waste disposal Facility as defined by MGL c
I 11. S I 50A.
The debris will be transported by:
(name ot'hauler)
The debris will be disposed of in
5,1e —
�1 CF�--" ?
(name of facility)
OQ:=,a.& off (- 1 5;-
(addre.ss of*facility)
signature of permit applicant
cs /01 /08
(late
CITY OF &U EM
PUBLIC PROPERTY
DEPARTMENT
K1f01,4i1SY taw•n
NnvOR 130 WA9alx.TON STREET•SAI EM %1ws&Aansr s 01970
TEL 97a.745.959S 9 FAX.97&740.9&4
HOMEOWNER LICENSE EXEMPTION
Please Print
Date ostoi Joe
Job Location c. S
Home Owner Address 41 W 41 tz� s I-
Home Owner Telephone R 78 - 7`I f - 3 7&y
Present Mailing Address y I w. ( +ef 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 who,does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Persons) 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 "homeownee*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 SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code