24 WINTHROP ST - BUILDING INSPECTION The Commonwealth of Massachusetts
W
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CIcEIVED SALEM
�y( pG ��It� EERV)CE RevisedMar2011
n Building:Pemiit Application To Construct,Re ai r emolish a
J� One-or Two-Family Dwelling
This Section For Official UsIMIJA
j Building Permit Number: Date Applied:
0 & l$ IS
Budding Official(Print Name) Signature - Date
ESECTION 1:SITE INFORMATION
1.1 Pro erty Address. 1.2 Assessors Map&Parcel Numbers
24 W I► J:nl{RoP S r
1.1 a Is this an accepted street?yes x no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(it)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check if yes❑ I Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIPI
2.1 Owner'of Record: `
W ENnv Sp Kur-,t s SRc 7-M kA 00-1-0
Name(Print) I City,State,ZIP
a`I ytIN oP ST 3t0 503 9255 t�1e�t�IuS2mue_A�Sbc I '
No.and Street Telephone mail Address
SECTION 3:DESCRIPTION OF PROPOSED WOW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description
i l of Proposed Work : tr (3 ;_-lOD_
l o M U J L)lu G
PCrs() FTQAc / INSTprtl - 4 f+E�i
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ 7p pv-0 I. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ d ❑Standard City/Town Application Fee
Cl Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ (TV 0 2. Other Fees: '
4.Mechanical (HVAC) $ List: /{j 6 (�
5.Mechanical (Fire
I Suppression $ Total All Fees:$
`V1 Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ OOfl ❑Paid in Full ❑Outstanding Balance Due:
i
SECTION 5: CONSTRUCTION SERVICES ~
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see 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 Masorry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name HIC Registration Number Expiration Date
No.and Street Email address
City/Town,State ZIP Telephone
SECTION Gt 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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW 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.
W5-t,4 1-N YA 00,S 5 I -15
Print Owner' 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 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.mass.gow'oca Information on the Construction Supervisor License can be found at wtviv.mass.aov/dns
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 halffbaths
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 SALEM, MASSAC HUSETTS
BUILDING DEPARTMENT
120 WASI-IINGTON STREET,3"D FLOOR
TEL. (978)745-9595
FAX(978)740-9846
KINMERLEY DRISCOLL
MAYOR Tf IoMAs STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMbIISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT`
Date 5lt`a ' 15 \
Job Location d-L W I ti1Th4KDQ ST-, 64iL-A-1 MA 014-70
Home Owner Address AS M04
Present Mailing Address Z(o 40B CT SAZLk LAA 009Z-0
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
QTY OF SALEM) MASSAaiUSE M
j2
BUILDING DEPARTMENT
€_ ti
120 WASHINGTON STREET,YO R5,OOR
TEL.(978)745-9595
KBEERLEYDRISCC)LL FAX(978)740-9846
MAYOR TrIOMAS STREMM
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
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 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:
2AsOu.A
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signatur of applicant
5 -/� -15
Date