31 CIRCLE HILL ROAD - BUILDING JACKET � e ,
The Commonwealth of Massachusetts RECE Vrn
Board of Building Regulations and Standards rSPECf loti l S .
Massachusetts State Building Code,780 CMR it 2
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or o a
'�6:���A 2
One-or Two-Family Dwelling
This Section For Official,Use Ouky'
Buildtng Permit Number: Date
Building Official(Print Name) Signature Date
�p 'SECnON l:SITE INFORMATION '
1.1 Prope(!rty4�
Address: 1.2 Assessors Map&Parcel Numbers
Li a
� 1.1 an a Is this accepted street?yes K no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.-Le.40,§541) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP;
1 Owner;of Record: -.
a s is <Ale,.,, r, agm
Name(Print) City,State,ZIP
3) C:Icli 9 11 tJ
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(Check all that apply)
New Construction❑ Existing Building i!] Owner-Occupied I6 I Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ 1 Number of Units I Other ❑ Specify:
Brief Description of Proposed Work-2: .r L. . Q.
` SECTION 4:ESTIMATED CONSTRUCTION COSTS '
Item Estimated Costs: Official Use Only
abor and Materials -
1.Building $ 1: Building Permit Fee:$ ' Indicate how fee is determined;
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: �$ �'J `1
4.Mechanical (HVAC) $ :List: 7tS"/ r/
e
5.Mechanical (Fire $ Total All Fees:$
Suppression)
�\ rCheck No: Check Amount: , Cash Amount
6.Total Project Cost: $ /G (J ❑paid in Pull ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holderf,_
II N : �), t h v uL List CSL Type(see below)
No.and Street Type Description
U Unrestricted uildin s up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State,ZIP Telephone
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...........❑
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:OWNER'OR AUTHORIZED AGENT DECLARATION
fried
oting my name below,I hereby attest under the pains and penalties of perjury that all of the information
in this application is true and accurate to the best of my knowledge and understanding.
P ' wner' or Au orized Agent's Name(Electronic Signature) 2 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
.vww.mass.gov:'oca Information on the Construction Supervisor License can be found at www.mass.eov/dns
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) 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"
I ,13
I I I I
cQ
c
+'j919
31 Circle Hill Rd. 2
i
No. 4A -0 City of Salem Ward I
4000NC�
APPLICATION
FOR
PERMIT TO BUILD ADDITION, MAKE ALTERATIONS OR NEW CONSTRUCTION
IMPORTANT-Applicant to complete allIX
in sections:1, ll, Ill, IV, and I
I. AT(LOCATION) 31 C r i-c/e, IX, L I 77-
ZONINCT
)
LOCATION (NO.)I� f fsrnEET) r ' C
OF BETWEEN ''QQ O G K d � `Q AND
BUILDING CROSS STREET) (CROSSSTREET)
SUBDIVISION LOT BLOCK SIZE
II. TYPE AND COST OF BUILDING -All applicants complete Parts A -D
A. TYPE OF IMPROVEMENT D. PROPOSED USE-FOR"DEMOLITION'USE MOST RECENT USE
1 ❑ New building Residential Nonresidential
2 ❑ Addition(If residential,enter number of new 12 One family 18 E] Amusement,recreational
housing units added,itany,in part D,13) t--W 19 ❑ Chruch,other religious
13 ❑ Two or more family-Enter number
3,g Alteration(See 2 above) of units....................................................... 20 ❑ Industrial
21 ❑ Parking garage
4 ❑ Repair replacement 14 ❑ Transient hotel,motel,or dormitory- 22 ❑ Service station,repair garage
Enter number of units ...........................
5 ❑ Wrecking(B multifamily residential,enter number 23 ❑ Hospital,institutional
of units in building in Part D,13) 15 ❑ Garage
24 ❑ Office,bank,professional
6 ❑ Moving(relocation) 16 ❑ Carport 25 ❑ Public utility
7 ❑ Foundation only 17 ❑ Other Specify 27
E] School,library,other educational
B.OWNERSHIP 27 ❑ Stores,mercantile
28 ❑ Tanks,towers
8 Private(individual,wrporetion,nonprofit
institution,etc.) ` � . .. 29 ❑ Other-Specify
9 ❑ Public(Federal,State,or local government
C.COST (Omit cents) Nonresidential-Describe in detail proposed use of buildings,e.g.,food processing plant,
machine shop,laundry building at hospital,elementary school,secondary school,college,
parochial school,parking garage for department store,rental office building,office building
10. Cost of improvement ......................................................... $ at industrial plant.If use of existing building is being changed,enter proposed use.
To be installed but not included
in the above cost
a. Electrical...........................................................................
b. Plumbing..........................................................................
c. Heating,air conditioning.............................................
d. Other(elevator,etc.).....................................................
11. TOTAL COST OF IMPROVEMENT $
III. SELECTED CHARACTERISTICS OF UILDING •For new buildings and additions, complete Parts E-L;demolition,
complete only Parts J& M, all others skip to IV
E. PRINCIPAL TYPE OF FRAME F. PRINCIPAL TYPE OF HEATING FUEL G. TYPE OF SEWAGE DISPOSAL I. TYPE OF MECHANICAL
30 ❑ Masonry(wall bearing) 35 fq Gas 4Q4�Public or private company Will there be central air
31 ® Wood frame 36 ❑ Oil 41 E] Private(septic tank,eta) conditioning?
32 ❑ Structural steel 37 ❑ Electricity 44 ❑ Yes 45 NN.
33 ❑ Reinforced concrete 38 ❑ Coal H. TYPE OF WATER SUPPLY Will there by an elevator?
34 ❑ Other-Specify 39 ❑ Other-Specify 42 ErPublil or private company 46 ❑ Yes 47,$No
43 ❑ Private(well,cistern)
J.DIMENSIONS M. DEMOLITION OF STRUCTURES:
48. Number of stones ............................................................
49. Total squarefeetf floor area,
all floors,based o Has Approval from Historical Commission been received
nexterior a
dimens.ons ..............................................................._....... for any structure over fifty(50)years? Yes_ No
50. Taal land area,sq.n....................................................... Dig Safe Number
K.NUMBER OF OFF-STREET PARKING SPACES Pest Control:
51. Enclosed ............................................
52. Outdoors HAVE THE FOLLOWING UTILITIES BEEN DISCONNECTED?
Yes No
L RESIDENTIAL BUILDINGS ONLY Water:
53. Enclosed ..............:.............................................................. Electric:
Gas:
Full.... .-.. Sewer:
54. Number of
bathrooms DOCUMENTATION FOR THE ABOVE MUST BE ATTACHED
Partial.------------------. BEFORE A PERMIT CAN BE ISSUED.
IV. COMPLETE THE FOLLOWING: - -
Historic District? Yes_ No (If yes, please enclose documentation from Hist. Com.)
Conservation Area? Yes_ No (If yes, please enclose Order of Conditions)
Has Fire Prevention approved and stamped plans or applications? Yes No_
Is property located in the S.R.A. distric . Yes_ No
Comply with Zoning? Yes No no,enclose Board of Appeal decision)
Is lot grandfathered? Yes_ No (If yes,submit documentation/if no,submit Boar of Appeal decision)
If new construction, has the proper Routing Slip been enclosed? Yes_ o
Is Architectural Access Board approval required? Yes_ No (If yes,submit documentation)
Massachusetts State Contractor License # Salem License #
Home Improvement Contractor# Homeowners Exempt form(if applicable) Yes_ No
CONSTRUCTION TO BE COMMENCED WITHIN SIX (6)MONTHS OF ISSUANCE OF BUILDING PERMIT
If an extension is necessary, please submit
CONSTRUCTION IS TO BE COMPLETED BY: in writing to the Inspector of Buildings.
V. IDENTIFICATION - To be completed by all applicants
Name Mailing address-Number,street,city,and state ZIP Code Tel.No.
Owner or
Lessee ivti u l d a vv l c ' Q
2.
Contractor Builder's
U-) License No.
3.
hitect or
T-
ngineet
I hereby that the proposed work is thorized 14y the owner of record and that I have been authorized by the owner to make this application
as his ut 'zed agent a agree to conform to all applicable laws of this jurisdiction.
Sig a e of plicant - Address Application date
DO NOT WRITE BELOW THIS LINE
VI. VALIDATION
Building //// G'_ FOR DEPARTMENT USE ONLY
Permit number 1 7 0
Building Use Group
Permit issued 19
Fire Grading
BuildinPermit Fee $ �(/ Q �° J(
1 p Live Loading
Certificate of OccupancyApproved by:
$ Occupancy Load
Drain Tile $ '
Plan Review Fee $
TITL
NOTES AND Data•(For department use)
LIU ctiL�
z « L L ,�
PERMIT TO BE MAILED TO:
DATE MAILED:
Construction to be started by: Completed by:
VI ZONING PLAN EXAMINERS NOTES
DISTRICT
USE
FRONT YARD
SIDE YARD SIDE YARD
REAR YARD
NOTES
SITE OR PLOT PLAN -For Applicant Use
O N
3
VI cPPPR°` la°`EFS[cEs P Eerie 0 °�Me1Y
/ Yw ems' o Epp<ct�ov°eoN•f0R
�pN Aot'. PEGS
feRES pyo e`\�E,.o
FpNCE E�.�hEF
SaZem Fz a Depaizxment.
F-i,ce Prevenz on Bureau
48 La4ayette Street
SaEem, Ma 01970
(508) 745-7777
t FIRE DEPARTMENT CERTIFICATE OF APPROVAL FOR BUILDING PERMIT
In accordance w.c th. the prov.i.6ton6 04 the Ma.64achu,6ett.6 State Bu,i 2d ing Code
and the Salem Faze Code, appZieation 4-6 hey eby made 4or approvaQ o4 ptan s
and tine Z44uance o4 a ee4t4jteate o4 approvaC So,t a buZZdtng penm<t by .the
SaZem Fuze DepaAtment. (Re4. Section 113. 3, Ma.6e. State BZdg. Code)
Job Location:
Owne2/Occupant:
ter: IK /N►?& ll: n
EZect,t ca.Z Contractor:
. ,.f ��'!-lam v r1!✓
Etre SupprCont uLr-ton.:
Si.gnan
tue 04
Appt--cant: i Phone 0:
Adct-ce 6,6 04 I C icy on.
AppZi.cant: � 11 Town:
Approval date: lr• '
CeAt.444cate 04 approval .L6 hereby 94anted, on approved ptan4 on. 6ubmc -tat
04 project de-taU. 6, by the SaZem Fine Department. AZl pt'=4 ante app-.owed
4otely 4o4 .i.dent1-44cation o4 type and eocati,on o4 44,te protection devtcea
and equipment. AZl pt,=4 ante 4ubjeet to approval 04 any other authoni.ty
hav-tng Ju4Z4d4ction. Upon eomptet on, the apP44cant on Zm4taeter(4) .6ha Z
4equ"t an tn.6peetLon and/or t4"t 04 the 44-te P-.ot x.44on devil ee6 and
equipment. ( ** FOR ADDITIONAL REQUIREMENTS, SEE REVERSE SIDE ** )
New conbtMAC tion.
P-WPeAty Zoeati.on ha4 no eompZianee with the prov44ton6 04
Chapter 148, Section 26 C/E, M.G. L. , relative to the
4."ta.latLon o4 approved 44,te aeaAm dev4.--". The owner o4
t IZ4 prope4aty " required to obta to eompZianr-e a s a
condi tion 04 obtatn-Lng a Su itding Pe4m4t.
u -Ptope-ty -Zocation -.i4 to eomptilance with the p4ov,44ton6 a
Chapter 148, Section 26 C/E, M.G. L. 4
t
Exp44 tion date:
.ig ee 04 Fire c.i,aZ
6� rs�3
Fee due: urulez 7, 500 Sq. Ft. 0. 0
7 , 500 So. Ft. ur Zazger - . 00 Fo-m #81 (Rev. !0!00 )
FIRE DEPARTMENT CERTIFICATE OF APPROVAL FOR BUILDING PERMIT
i
In compliance with the provision of Section 113.5 of the Massachusetts
State Building Code, and under guidelines agreed' upon by the Salem Bldg.
Inspector and the Salem Fire Chief, the applicant for a building permit
shall obtain the Certificate of Approval (see reverse side) and stamped
plan approval from the Salem Fire Prevention Bureau.
Said application and approval is required before a building permit may be
issued. The Massachusetts State Building Code requires compliance
approval of the Salem Fire Department, with reference to provisions of
Articles 4 and 12 of the Building Code, the Salem Fire Code, Massachusetts
General Laws, and 527 Code of Massachusetts Regulations.
The applicant shall submit this application with three (3) sets of plans,
drawn in sufficient clarity, to obtain stamped approval of the Salem Fire
Department. This applies for all new construction, substantial
alterations, change of use and/or occupancy, andanyother approvals
required by the Massachusetts General Lawe, and the Salem Fire Code.
Exception: Plans will not be required for structural work. when the
proposed work to be performed under the building permit will
got, in the opinion of the Building Inspector,`-eequire a
plan to show the nature and character of the 'Work to be
performed.
Notice: Plans are normally required for{ fire suppression ,
� systems,
fire alarm systems, tank installations, 'and Fire'Code
requirements.
Under the provisions of Article 22 of the Massachusetts' State Building
Code, certain proposed projects may not- require submission of plans or
complete compliance with new construction requirements:'In these
cases, provisions of Article 22, Appendix T, and Tables applicable
shall apply. This section shall not, 'however, supersede the
provisions outlined in the Salem Fire Prevention Regulations, Chapter
148, MGL, or 527 Code of Massachusetts Regulations. ' All permits for
fire code use and/or occupancy shall apply for the entire structure;
fire alarm and/or smoke detector installation shall apply to the
entire structure based upon current requirements as per Laws and/or
Codes, but the existing structure may comply with regulations
applicable for existing structures.
Notice: Sub-contractors may also be required to file individual
applications for a Fire Department Certificate of Approval
for the area of their work.. Such sub-contractors shall file
an Application to Install with the Fire prevention Bureau
prior to commencing any work for those areas applicable.
Form 81X (10/90)