21 WILLIAMS ST - BUILDING INSPECTION 7 I'he C'onumunsecahh of Mass:tchuseus - -
y; }� Board of Buildin g Regulations and Standards CI'i'1' OF
s Massachusetts State Building Code, 780 C'NIR SALEM
/trrued llar'nll
Building Permit Application 'ro Construct, Repair, Renovate Or Demolish a
Una-or Tivo-Fanol.v Du rllingr
This Section Fur Olreial Usc Only
Building Permit Number: ate Applied:
Building Uliicinl(Frin(Nmnel Signalu Dale
SECTION 1: SITE INFORMATION
i.l Property Add ease � ✓W�� Sla di 1.2 Assessors p Parcel Numbers
1.la Is this an accepted street? es no \lap Number Parcel Number
1.3 Zoning information: 1.4 Property Dimensions:
Lnning District Proposed(lse Lot Area(sq 11) Fronlage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rcsr Yard
Required Provided Required Provided Requind Provided
1.6 Water Supply:I14.O.1.c. Jo,§14) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Ihrblic❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site Jis
Check if es❑ P posal s)stem ❑
SECTION I: PROPERTY OWNERSHIP'
].I O)vJnn Record:
l( tl'Y'Lt J
11 � Ce Q.Q� MA 'D l�r7C�
Nmnc(Prior -- City.Stale,ZIP c.{
2( A�\Z WIC q �7`�
Nu.and Street Telephone Email Address
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction ❑ Existing Building Owner-Occupied Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specit)t:
Brief Description of Proposed Work': t? p
SECTION J: ESTIMATED CONSTRUCTION COSTS
Ilem Estimated Costs: O111clol Use Only
(Labur mtd ..\laterials) y
I. OuilJing ma)
1. Building Permit Fee: S Indicate Fh
etermined:
'. l:'lectrical S ❑Standard CirylTown Application fee
- ❑Total Project('ustr(item 6).x muUiplier 1. I'hunhing SOther Fres: SJ. Mechanical i11% \('1 $ List:—Sr+nal .\II Fecs: S('heck No. ('heckAnxm: C :
Total Prnjcct Cush i ❑ paid in Full ❑UwstanJing Oal:ut
SE(*IION5: CONSI-RUcrioNSERVICES
5.1 Construction Su lien isor License(CSL)
I
Pe Description
No. and Street I—1aV,1rtd(i)..'Idtagstp io- I TI)ol)ol. 11.)
(c.,tricted l&2 Fxnil) Mwifilill
Citii
Masoary
R c xin 7,-g cotcrinit
�%kj Wilidow;MLI Siding
SF Solid Fuel Miming Appliances
I Insulation
l'ele hone olition
Ismail address 1 1) 1 Deal
.4.2 Registered liume Improvement Contractor(HIC)
IIIC Registration Nunifier Expiration Dili:
111C Compan) Name orilIC liegistrant Nanic
No. mid Strict limail address
City/Town,State,ZIP relephaint
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152. § 25CM)
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 .......... a No...........0
SECTION 7s: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.
Print Owner's Naine(Elctarunic Signature) Date
SECTION 7b: OWNEWOR 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 Oa 5130 7-n
-r*. Name I 1:1MY-onic signature)
NOTES:
I. .\n 0%%ncr who obtains a building permit to do his her own work,or an owner who hires an unregistered contractor
(not registered in the Hume Improvement Contractor(HIC) Program),will&)J have access to the arbitration
o registered
' '
program or guaranty Nod under M.G.L. c. 142A. Other important information on the HIC Program can be Iliund at
i Information on the Construction Supervisor License can be found at t%
2. hen substantial work is planned. provide the information below:
totalIlour'Itea(,q
ow llourarca(sq. 11 1 including garage, finished basement.nitics•decks or porch I
living
" . , it"Is, Habitable room count
Gross It%iiigarea 114. It I
N tiniber offirellInces Number ol'bcdrooms
\umbvrot'bathroolus \t1lillivir ot'hall,haths
I %pe ot 11Q.1ting S)'teni N kimlive ofdecki, pordivs
FnJo,ed Open
Total Project ';qtiarc Foolage" 111A IV it'h1littitcd Itir total Project Co)l
y
CITY OF S.U.Em
PUBLIC PROPERTY
DEPARTIMENT
u.ous av nsarus 6
VA►ae I 7AOrMf.7[1a11TLir•IMAK VAauO,assrrs019V
ra rtii,s sssy • t<.%&975.74&IS"
HOMEOWNER LICENSE EXE.MFTION
Flew Frye
I
Data 5 3D
Job Laeados
Home Owner Address Nr
Home Owoor Telephone =<z --1
Present Maillsg Address !,j-\ryo
The current exemption ot"Homeownwe 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 licroso provided that the owner acts as supervisor.
DEFBNITION OF HOAaOWNES
Persons) who owns a parcel of laod on which he/she resides or intends to reside.on
which there is, or is intended to ba,a one at two family dweWng, attached or detached
.st uctura accessory to such use and/or torso struaturea A person who construct@ more
than one home in a two year period shall not be considered a homeowner. Such
-homeowner"shall submit to the Building Oillcial, on a form acceptable to the Building
Oillcial, that he/she be responsibly for all such work performed under the Building
Permit.
The undersipsed "homeowner"assumes responsibility for complimme with the State
Building Code and other applicable bylaws and regulations.
no undersigned "homeowner'certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
.viIt comply with said procedures and requirements,
HOMEOWNERS SIGNATURE LA l (� 1—
APPROVAL OF BUILDING CISPECTOR
See other side for state coda
CITY OF S.V-&Ni, AUSACHUSETTS
BLMDOW OEPAMUU\T
I'0 W-UHNGTON STREET, J`FZ.00R
l*RL k973) 745-9595
KD COF F LBY DIILSCOLL FAX(974) 140.934d
NCAYOX T}iO.mU ST.PMUS
OlnEcran OP pL 9LlC pROVH1<TY/9vanL 1G C01LVts3,OV ER
Construction Debris Disposal At'17davit
(required for all demolition and rcnovation work)
In accordance with the sixth edition of the State Building Cade, 730 CMR section 111.1
Debris, and the provisions of MGL o 40, 3 34;
Building Permit is is issued with the condition that the dcbris resulting from
This work shall be disposed of in a properly licensed waste disposal facility as doBncd by NIGL c
l 11. S 150A.
The debris will be transported by:
an nLL--Lih.
(moot ol'htu er)
no debris wi II be disposed of in :
(namt of
1�Jdreo or f�cih�y)
1111namre of Permit 19plicint
:Jlt