30 WINTHROP ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SdMar
Y Revised Mar 2017
I Building Permit Application To Construct,Repair,Renovate Or Demolish a
j One-or Two-Family Dwelling
1 This Section For Official Use Only
Building Permit Number: Da eAppplied:
Building Official(Print Name) Signatur Date
SECTION 1: SITE INFO A
1.1 Property Address: O .l;.t tv4� � S�'6& 1.2 Assessors ap& Parcel Numbers
3 A
L la Is this an accepted street?yes 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 upply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Private❑ Zone: _ Outside Flood Zone? Municipal @41 site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.t Owner of Record:DA Ian
DAM L K SAS MA 0 19�10
ame(Print) City,State,ZIP
1X2 win-THRCP S'17�1` 9-&&61=166
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ 1 Existing Building 01
Owner-Occupied WT Repairs(s) ❑ 1 Alteration(s) 021 Addition ❑
Demolition arl Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Work 2:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ O 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ �O� ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x -
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
�7 Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ �j G'Oe,Ov 0 Paid in Full 0 Outstanding Balance Due:
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 Masonry
RC Roofing Coveting
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State,ZIP Telephone
SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.g 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 BUILDINGPERMIT
I,as Owner of the subject property,hereby authorize
to act onmy behalf, in allmatters relative to work authorized by thl utl mg permit application
Print Owner's N.t ( lectronic Signature) Date'
SECTION 7b: OWNER' 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 my 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 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.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/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. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF S.U. -m
PUBLIC PROPERTY
DEPART1dENT
wat�n ne='•r 6
Vwrae 130 WMMNG M t+nasr SDK Vwa�oR'sarn 011-0
M 9-6-741.95"•FAA 178-746904
HOMEOWNER LICENSE EXE.MMON
Plesse "I V
Dan _
Job Lceadm 36 W ta�cc-np stc eQ ,
Home Owner Address
Home Owner Telephone Q 7S 1[7
Present Marling Address —A-e> w w
e
The current exemption of"Homeowners"was extended to include owneroccupied
dwellings of two Units or less and to allow such homeowners to engage an individual for
hire who does not posses a licenser provided that the owner seta as supervisor.
DEFINMON OF HOMEOWNER
Person(s) who owns a parcel of land on which hatsho resides or intends to resider on
which there is, or is intended to bee 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
Oillcial, 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
.vill comply with said procedures and requirements.
HO.IEOWNERS SIGNATURE
.APPROVAL OF SUILDNG NSPE R �+ /
See other side for state code
CITY OF S.U.E.`I, ��LiSS.�CHL'SETTS
BL'II.D(NG DEPARTNONT
110 WASHLYGTON STREET, 3i0 FLOOR
T1:L (978) 745-959S
F.Vt(978) 740-9846
KI.NfBERLEY DRISCOLL
MAYOR TliO WS ST.Pmm
DIRECTOR OF PLBLIc PROPERTY/HCQ.DLNG CO\L\IISsIOVER
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 1 l 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit p 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 MGL c
111, S 150A.
The
de ris will
be
tra
nsported by:
J!
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
v na Lure ofpermrt app scant
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