23 WILLIAMS ST - BUILDING INSPECTION 1
The Commonwealth of Massachusetts
GYI } Board of Building Regulations and Standards CITY
N OF SALEM
y j Massachusetts Stale Building Code, 780 CMR, 7 edition
r Revised Jwruury
Building Permit Applicatioan'o Construct, Repair, Renovate Or Demolish a /. :.MAY
On or Two-Fumdv Dwelling
JThis Section For Official Vic Only
Building Permit N mber: �. �. r Date plied:
Signature: ' V'3n'o \ l I ! Yl B/
Build' g Commissi /Inspector of Bui, ' Date
SECTION : SITE INFORMATION
1.1 Property1l dress: 1.2 Assessors Map& Parcel Numbers
3 WI[4svr3 sr
L l a Is this an accepted street?yes no Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(B)
1.5 Building Setbacks(R)
Front 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 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public O Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
A!)FGGG ryRE.5JX4Ig2,/11GeJ# a 3 G<re l�iR�3 S r S.a LeH�ry
Name(Print) Address for Service:
i 7n SM9 --7s3g
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ 1 Repairs(s) Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of (P A S ! IjAc L SN1.4,f" [4[L Jd
JA/S7.7 ff.k orw4r,E[t Sa![rPt0.7N44 1 am /LD r H
GA IAA�S 3U `X AkS L/Ac.-f' ccF 5"(^,Get5 L.[J sAew f7`[S 6ts1Id-(4)
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and MaterialsI. Building S �j 1. Building Permit Fee: S Indicate how 1'ee is deter
2. Electrical S ❑Standard Cityllbwn Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S �l
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire S
Su ression Total All Fees: S
Check No. Check Amount: Cash Amount:
6.Total Project Cost: S �Q �Q 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) /Q
& m AC(44A) License Number I:x imli n Date
nn�
Name of C'S1.• dJer Type(see below) K :
`A) List CSL Wf• t7
rs Pe Description
Add t4i � U Unrestricted u to 35,000 Cu.Ft.
���f R Restricted IB2 Family Dwelling
Signal rc M Masonry Only
Q9$-S3/-I4ef RC Residential Routing Coverin
fcicphone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5,2Regbtered Horne ImprovementGGontnctor(HIC) /Q 27
C cTY /ems mar/C�9
tilt Com any ame or 11 C Rcgistrnrtt 11�� a Registration umber
Addressp j
spiry on Date
Signuluiv 6 Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.1 2SC(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...........O
SECTION 7n: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.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1. {{/ ,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 —
Signature offRyncr or Authorized A en Date
(Signed under t pains and penalties o 'u
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#a(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 I IO.R6 and I IO.RS,respectively.
?. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basementiattics,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
T)peof cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
CITY OF S.U.E.ti(, N LAsS.ACHU5ET-rS
acaDLVG 0FP.%RM11 NT
I_'0 WASHNGTON STIMM. 1'e FLOOR
T1tL (978) 745.9599
FAX(97Iq 14498"
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Address,
City/state/zia
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for nr ie may capsity, waken'Comp.6nuesaea 9. ❑DaiWiry addhion
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Rne up to S I.J00.00 saWar ono-you imprisonmwK a9 we4 AS Civil pen,Miu ill the faro-of a STOP WORK ORDER'and a floe
Of up to S2mo0,day eilainta the violator. IN Wvi.%W charm copy of this,tatemem maybe I'urwtrdad to the 0111ee of
I n.c su eariuns of t ho 111A for insrrrancs coverage vuretkacioa
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City orfutvn: YermiNl.leenrt/__ __ ___
Ivufail Aulhurtly (circle nee):
I Huard u(Ileallb 1. Htubllna Mparrmvnt I. Cily/fovea Clerk 1. flocirical 6npcctor S. Ptunrbtae Impector
6. clrher . _
(_•.M ace Peflon: _ _ Phone a.
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.. I c V"w a�e...4v)I Rl'r 5d11 M.
I'.11: M 111 "III... �
rII: v74:1.V1MA �1•fir:'/76.aS'1aM
construction
Debris
rca' j vit
um%l W allmuhtionw) no �n wor
In accunlattce with the sixth edition of the Mate Building Cods. 730 CMR section 111.3
provisions of MGL a 30, u
Debris, and the pro MGL e
is issued with the condition that the debris molting
Ouildilig Permit M ► licensed waste disposal focaity as defined by
this work shall he disposed of in a proper y
111. S 150A.
The debris will be transported bY:
I,,saw u hauled
The debris will be disposed of in :
(name ul a¢I ny
ee,a nr raaIllyl
I two nl Iwemit a pl' ant ,
/O 6
I later