43R WALTER ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
WN Board of Building Regulations and Standards CITY
f `� OF SALEM
Massachusetts State Building Code, 780 CMR, Th edition Revised Jmumry
Building Permit Application To Construct, Repair, Renovate Or Demolish a I• 1004
One-or Two-Family Dwelling
his Section For fcial Use Only
Building Permit Number: Date Applied:
Signature: 2 � '
BuildirfgCommission,rrrn ctorofBuil-ings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
55-E
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
From Yard Side Yards Rear Yard
Required Provided Required Pon-dcd Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private ❑ Check if yes❑ P P y
SECTION 2: PROPERTY OWNERSHIP'
2.1 r,'of Rec!1� 6fc Li
I�t, r, 1-2, —
Na print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ 1 Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Briet_Descrption of Proposed Work': '
`/. tti�N� Q G(t•PC r s r's -ecr O.M-,Z,--
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ 1. Building Permit Fee: $ Indicate how fie is determined:
2. Electrical g ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (FIVAC) S List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Q Check No. Check Amount: Cash Amount:
6.Total Project Cost: ❑Paid in Full ❑Outstanding Balance Due:
_ [ l` WILLIvrz�,
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL-I]older
List C'SL'I'}'pe(see below)
:\ddress f' a Description
U Unrestricted(up to 35,000 Cu. Ft.)
R Restricted I&2 Familv Dwelling
Signature M Nlasonry Only
RC Residential Roofing Covering
Telephone WS
Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature 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.
Signature of Owner Date
IS'ECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, �riYjn p," 1`^Q'''z,�7-Z ,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
behal .
Print e
Signature o Owner or uffi d gent hale
Signed under the pains and enal[iAes of er'u
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I I0.115, respectively.
2. When substantial work is planned, provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) I labitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half7baths
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'
FORMERLY HARRIS i PHILBRICK
ro
(2f) � is
71,17-------------------------
I IG.Z4
otl
LOT B • 41.54 0
3868 S.F. 4 x z
W.
< 0 el
-LOT A m 0
0
0 1
443 i'S.F 0
1
HOUSE
RIGHT Or WAY LAJ
0
9.16 ——— ——-
85.54 - 76.79 <
------- ---------------
HOUSE
CLARKE
LAND OF M A R I A C. L E B R U N
WALTER ST., SALEM, MASS.
SCALE I IN.=20FT. JULY1948
Quka4
Top OecK
LD
FTI
FTI ff T[TTI
Ilxry
/01
' /' f '• r n
f /
{
-Top Ve % A1
jag
s
f fv
a s- Feet �,!. �
3d
� ii i s is
I—+ c�P�( �x+!
c
1�
_.._ _ _ __._.. I
CITY OF SMYE
PUBLIC PROPERTY
DEPARTMENT
Su,s.+ nsanxL
w,ro. t 3a vtQ�auMc�an s7.asr�s�u+a wsunw seats OH-o
M 9-L7+i9$"•FAX 976-746964
HOMEOWNER LICENSE EXE.rtPTION
Flew Ftri�t
Date 3- 2zd i
Job Location
Home Owner
Address
Home Owner Telephone l l- (7 9 - Cz I
Prea d Mailing Address—`4 Kl t u H-Pr �l
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or teas and to allow such homeowner to engage an individual for
hire who.does not possess a license,provided that the owner acts as supervisor.
DEFIN MON OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to resider 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 pawn 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 wort 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
will comply with said procedures and equirements.
HOMEOWNERS SiGNAT(.'RE u,
APPROVAL OF BUILDING NSPECTOR
See other side for state code