52 WEBB ST - BUILDING INSPECTION (2) � � � �O �D O
� The Commonwealffi of Massachusetts
/ A� Boazd of Building Regulations and Standazds CITY
f ,� Massachusetts State Building Code, 780 CMR, 7`�edition OF SALEM
y��� Revised January
� I Building Permit Application To Construct,Repair, Renovate Or Demolish a 1, 2008
One-or Two-Family Dwelling
This Sectio Official Use Only
Building Permit N ber. Date Applied:
Signature: -"�Gr�'a �
Building Commissioner/Inspector of uildings Date �
SECTION 1: SITE INFORMATION
11 Property Address: C,� `,t�� �` , 1.2 Assessors Map&Parcel�Numliers ; �,,.�nm.�;;r-i:�r"
J Y1M
1.1 a I5[his an accepted street?yes no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning Disfict Proposed Use Lot Area(sq ft) Fron[age(ft)
1.5 Building Setbacks(fr)
Fron[Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewa e Disposal System:
Public'6� Private❑ Zone: _ Outside Flood Zone? Municipal�l On site disposal system ❑
Check if yes�
SECTION 2: PROPERTY OWNERSHIP�
2.1 Own�r�,`�ofRe��.�f. S�CLS�� SZ ���U 51'
Name(Print) Address for Service:
' °11��51°- S3`1�
� Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construcfion ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
� Brief Description of Proposed Worl�: e �1�1�4 sV {I
I.�Md.��t A �+ �j�u•'�Ea.'�.\�h�L.`\•
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 2Sp� 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Apptication Fee
2.Electrical $ S W ❑Total Project Cost'(Item 6)x multiQlier x
3.Plumbing $ 2, Other Fees: $
4. Mechanical (HVAC) $ L���
5.Mechanical (Fire $
Su ression Total All Fees:$
� �Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ Q W ❑paid in Full ❑Outstanding Balance Due:
db '�� ;�a : i �� Gi��,�«��
[ �
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Coostruction Supervisor(CSL)
License Number Expitation Date
Name of CSL-Holder Lis[CSL Type(see below)
Address T e - Descri tion
U Unrestricted u to 35,000 Cu.Ft.
R Restricted 1&2 Famil Dwellin
Signature M Mason Onl �
� RC Residential Roofin Coverin �
Telephone WS Residential Window and Sidin �
SF Residential Solid Fuel Bumin A liance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HiC)
HIC Company Name or HIC Regishznt Name Registration Number
Address
Expirntion 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
relafive to work authorized by this building pertnit application.
Si ature of Owner Date
SECTION 7b: OWNER' OR AOTHORIZED 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
Signazure of Owner or Authorized Agent Date
Si ed under the ains and enalties of e '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 azbitration
program or guaranty fund under M.G.L. c. 142A.Other important information o�the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations ]]O.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.) (including garage,finished basemenUattics,decks or porch)
Gross living azea(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"
,: CITY OF S�1L.E��I, I�L�SS.-�CHUSETTS
• BI;iLDL�IG DEPAA"I1(E�iT
' l?O W.�SHL�IGTON$TREfiT, �iD F100R
� TtL (97� 7�5-9595
F,�x(97� 7�9846
���FRf RY DRISCOI.L
�1AYOR IHo.�tAs ST.PutY4R
DIREGTOR OF PCHLIC PROPEAlY�HI'II�L�1G CO\L\(ISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 1 l I.5
Debris, and tho 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 wasta disposal facility as de6ncd by MGL c
11 l, S 150A.
The debris will be transpoRed by:
������
(n�unc of hauler)
The debris will be disposed of in :
N��J1� ���1��
-- (name of facility)
SD�,'4��,\�a
(addnss of facility)
�
� signature of permit applicant
53�11
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CITY OF S.�i.E.tiL
PUBLIC PROPERIY
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hitr who.doa not poaes�a 8t�M1 P+��dad that th�ow�n�aeb a�aupa�viaor
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whieb thee�i� or.ia intaodad ro br,a oot or two fJ�mily Q�veWn�,atfaehed or dabehed
etrueturea aeceswry w auch uu and/a lf�rrm a4votura. A pe�os who camtrucu rtwn
thaa on�hom� io a nvo year pariod ahaU noe b�eontidaed a homeownar. Sueb
"homeownd'�hal1 �ubmit W t1u Huildin�OQlcial, on s fonn aeteptabll to th�Buildins
Ot1lcial, that hdeh�b�rapon�ibl�tor all�uch work perfonned uader�1u 8uildln�
Pmnit
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Bwldin� Dryartment minimum inapatio procedura �nd requimnenq and that hdshe
�vill eomply wirb �aid proeadura and req 'remmts.
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Partial lst Revisions
1� rl�Or ��O�S�ltionstothe DMS design, llc " na`e
�i' Plan Architectural Design Services
.
� Resldence
Scale: i/q"=i-o" ioo Cummings Center,Suite qzqG
Sz Webb Street,Salem,MA oig7o B�'erly,MA oi9i5 .
Date:Mayz,zoii Phone:97$-57$-574$
Drawnby: dms '. Fa�c:866-6q8-825i
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LEGEND: �"
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