78 WEBB ST - BUILDING INSPECTION 2. •`10
The Commonwealth of Massachusetts
js. Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
yr" Revised:Liar 201l
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: D e Applied:
Building Official(Print Name) Signature _Date-a
SECTION I:SITE INFORMATION C-)
LI Proper Afire s: 1.2 Assessors Map& Parcel Numbers e'� o�
7S P-b� S1 r Sa� I M�1 N yrn
I.la Is this an accepted street?yis__-)c no Map Number Parcel Number r<
1.3 "Zoning Information: 1.4 Property Dimensions: 7MC
0
_ R <
Zoning District Proposed U,ve Lot Area(sq It) Frontage(tl) G zi
1.5 Building Setbacks(ft) Ul
to
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(NLG.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private 0 Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Checkifyes❑
SECTION 2: PROPERTY OWNERSHIP[
2.1 O nerI oqf 11 d:
,eit�s ,o,A 0.arrolk � AI (7, Jca�em , MA
Name( 'nnB City,Slate,ZIP
_ 7B V eb�i (`!78 Y&Ya7y
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(cheek:dl that apply)
New Construction ❑ Existing Building Owner-Occupied Repairs(s) ❑ 1 Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specily:
Brief Descriptio of Proposed Work':
c P- khrl� �,livirlhXA/ �,Xjl x
1. --
SECTION 4: ES-I INIATF,D CONSTRUCTI0.9COSTS
Item Estimated Costs: Official Use Only
Labor and Nlaterials
1. Building $ 5 O, I. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ �t ❑ Standard City/town Application Fee
Iv ❑Total Project Cost'(Item 6)s multiplier x
3. Plumbing $ 2. Other Fees: $ 1-1
4. Mechanical (I-IVAC) S List: C�//�j� �iC)
5. Mechanical (Fire $ -
Suppression) "total All Fees: $
Check No. Check Amount: Cash Amount
6. Total Project Cost: $ L6 t� ❑ Paid in Full ❑Outstanding Balance Due:
b
L t �
SECTION 5.• CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSI.Holder
List CSL"Type(sec below)
No.and Street Type Description
U Unrestricted(Buildings 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
w
SF Solid Fuel Burning Appliances
..i 1 Insulation
Telephone. Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or Ii1C 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.
r�
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Nmne(Electronic Signature) _ - De to
-- 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 M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.nmss.gov/oca Information on the Construction Supervisor License-can be found at www.mass.eov/dos
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. "I'olal Project Square Footage"may be substituted for"Total Project Cost"
CITY OF SALEM, MASSACHNSETTS
BUILDING DEPARTMENT
r�
120 WASFUNGTON STREET,YD FLOOR
�crn,�a TEL. (978) 745-9595
FAX(978) 740-9846
KINMERLEY DRISCOLL
MAYOR TY-IOmAs STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONMUSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEAnwi4-
Job
Date
Location _ I
J_� *�
• �C 'Ceyn
Home Owner Address �4 \ ,,vwn S+
W . A
Present Mailing Address v ob� S�• A
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 that does not possess a
license, provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s) 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 "homeowner" certifies that he/she understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR
CITY OF S�V E,tif, ,%LkSS,ICNUSETTS
BL'tLpXNG DEPARTMIUNT
130 CV.ISHLNGTON ST tEBT, 3w FLOOR
ei TEL (973) 745-9395
KIALBUr Py DRISCOLL F.',v(978) 7-10-93-5
bLiYO;'t
I�-IOSt.�3 ST.Pl^c.iltg
DIRECI•GR OF PULIC PROPERTY/aL:M0LNG CONWISSLONER
Construction Debris Disposal Aftldavit
(required for all demolition and renovation worts)
In accordance with the sixth edition of the State Building Coda, 730 CbfR sactian I l I.S
Debris, and the provisions of MGL c 40, S j4;
Building Perrnit # 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 b1GL c
111, S 150A.
The
debris will b\e-tr`ansportcd by: 1
tlwvier
(iwntc at hautcr) /
The debris Will be disposed of in
-
,oral 1�otYts�er S-�a1.71 oYa
(name of taeilil
boLLrne� M A
(.�d�tes.c of raahr�)
sign�rure u['prrntirn , --
F PGeant
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