14 WINTER ST - BUILDING INSPECTION (4) w 2 �SO� C L� 21 2-
RECEIVED
The Commonwealth of Nlassachusttf CITY OF
i Board of Building Regulations and Standards SALEM
0 � Massachusetts State Building Code, 7801O4IIAPR —8 A 11: R�vised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Onl
Building Permit Number: Date A plied: �.
_y Building 011iciul(Print Name). Signature•
t SECTION C SITE INFORtNIATION
LI Proqa�rty Addrgss: L2 Assessors binp&Parcel Numbers
lgl latn�>r S�rQ¢t
I.I a Is this an acce ted street9 yes _ no Map Number Parcel Number
1.3L Information: Ld Property Dimensions:
"Coning District - Proposed Use Lat Area(sy R) Frontage(It)
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.401§54) 1.7 Flood Zone Information: t.s Sewage Disposal System:
Zone: Outside Flood Zone?
Public Private❑ Check if es❑
Municipal O On site disposal system ❑
. _
� ' SECTION 2: PROPERTY OWNERSHIP`
2.1 Owner_.f Rcco T
lW�.�w y, ,ytf/'1<t, �•�/01 /�/7 �'7 V
/�r4th me( City,State,
)•�
te,ZIP n. �rin �nJlh ` - / rr- �y C KQ� 'D'A.t
�rr rpA
No.and Street Telephone C•mail AJJnsg
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Buildin Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition Al Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed%V k-:
eN,
1 �
CONSTRUCTION COSTS
SECTION a: ESTIMATED COt r
Estimated Costs: OfOcial Use Only
Item Labor and Materials -
I. Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
3 O�D (3 Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 9,420 1�Qther Fees: S
d. Mcch:utical (I-IVAC) S 6- List:
5. Mechanical (Fire ,� Total All Fees:3—
Suppression)
. Check No._Check Amount: Cash Amount:
6. 'rutal Project Cost: $ a �� ❑ Paid in Full ❑Outstanding Balance Due:
G]V°
c::Ja a .3;,°1!SECTION 5: CONSTRUCTION SERVICES
5.1 Cmistructiorl Supervisor Licmise(CSL)
License Number Expiration Dale
Name of CSL Holder List CSL'rype(see below)
Type - :, Description .
No.;aid Strect -
U Unrestricted Ouildin tip-to 35,000 cu. Il.)
R Restricted 1&2 Family Dwelling
Cilyfro%m,State,ZIP M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 I Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
1IIC Comp:my Name or HIC Registrant Name
No.mid Street - Email address
City/Town,State ZIP Telephone
SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G,L:c.152.§2$C(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 isluance of the building permit.
Signed Affidavit Attached? Yes ..........❑ No........... O
SECTION 7a:OWNER AUTHORIZATION:TO BE COMPLETED.WHENIL
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PEMUT'
1,as Own a bjec roperty;hereby authorize
t9 act on y eh f,in 1 tiers retain !e to+vork aut orized by this building permit application.
Print O+ ner s anie(Ele nic Signature) Difte
CTION 7b:OWNER t OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 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 lay knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 Hone Improvement Contractor(HIC) Program),will no have access to the arbitration
program or guaranty fund under NLG.L.c. II42A.Other importantinforration on the HIC-Pfogram c`att"be fount at _-- -"-
www m;us.emv'oca Information on the Construction Supervisor License can be round at ww++.mass.uo+:!dns
2. When substantial work is planned,provide the information below:
'Total floor area(sq. ft.) *It_(including garage, finished basement/attics,decks or porch)
Gross living area(sq. R.) 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"'rot:d Project Cost"
QTY OF SALEM, MASSACHUSE TTS
�n BUILDING DEPARTMENT'
120 WASFHNGTONSTREET,3" FLOOR
TEL. (978)745-9595
F
KIMBE]tLEY DRIS�LL FAX(978)740-9846
MAYOR THOMAS STTIERRE
DIRECPOROFPUBLICPROPERTY/BNLDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date 6
Job Location /`T Gv l/L rU J
Home Owner Address 44-.e
Present Mailing Address S�n�
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.
12, �
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR
CITY OF SALEA MASSA( HLBE M
BEziDnvc DEPAR7MENr
120 TA9 04G710NMEET,3IDFLOOR
UL(978)745.9595.
FAX(978)740.9846
SIb18ERiEYDRISQ'�I.L
MAYOR THOMAS STJUM
DntEcrmcFP mllcrRaFERTr/Buimm ooiansgomm
Construction Debris Disposa/Affidavit
(required for all demolition and,renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, S 54; Building Permit# is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of a i nt
Date