111 COLUMBUS AVE - BUILDING INSPECTION 25 cl3-�50 1 L4 L
The Commonwealth ofMassaehusetts RECEI `ED
I / Board of Building Regulations and Standards IMPECTIOisr L S 'ArL S
Massachusetts State Building Code,780 CMR RevireJ.L%ur 2011
r Building Permit Application To Construct, Repair, Renovate Or 4119oFJN 32 (.O I2: 0 2
One-or Tivo-Family Divel ing
This Section For Official Use only
Building Permit Number. Date Applled
zo
r -Building :Riicial(Print Name). Signature . Da
le
SECTION 1:SITE INEORtIVfAT1UN'
1.1 P o erty A Cress+: b S J 1.2 Assessors Map&Parcel Numbers
'17LI a Is this an acre lelld..street?yes no Map Number Parcel Number
1.3 Zoning Information: IA Property Dimensions:
Zoning District Proposed Use f orArca(sq R) - Frontage(R)
1.5 Building Setbacks(R)
Front Yard. . _ - Side Yards Rear Yard -
Requirod 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 O - Private O. Zona: _ Outside Flood Zoned Municipal O On site disposal system O
Check if ns0
SECTION I: PROPERTY OWNERSFiiP!
2.1 . wnert of Record: T6 Ste\ o (a`-1 p
Gke
ie(Print) "- � City,Stute,ZIP ff,,,,
] � I 0I vvV\ � Vrj V� ✓ � y'jg-22`r�D 4? VAI < e4� Bwr45 @CUwiCwS}
No.and Street
Telephone Email Address wCY
SECTION 3:DESCRIPTION OF PROPOSED\VORW(check all that apply)`
New Constntction C71Eiiisting Building O Owner-Occupied 0 1 Repairs(s) O 1 Alteration(s) O Addition O
Demolition O Accessory Bldg.0 Number of Units_ Other 0 Specify:
Brief Description of Proposed 1Vork3: C
ny�
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
❑Standard Cityfrown Application Fee
2.Electrical S 0 Total Project Cost?(item 6)s multiplier s
3. plumbing S P Qther Fees: S
d.Xlcchanical (tIVAC) S List:
5.Mechanical (Fire S Total All Fees:S
ression)
Check No. Check Amount: Cash Amount:
6.'f tel Project Cost: S UQ p 00 Cl Paid in Full O Outstanding Balance Due:
r--
i••yv`''1� �
'ItAP6l–t-1D 1 Z`�
y
SECTIONS: CONSTRUCTION SERVICES
5.1 ' rrstruction Supervisor License(CSL)
License Number Exptmtiun Dale
Name of CSL Ilolder
' List CSL'fype(see below)
No. and Street -
Type' - Description .
U Unrestricted(Buildings upi to 35,000 cu. Il.
R Restricted 1&2 Family Dwelling
Cityfrown,State,ZIP M mammy
RC Rooling Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 I Insulation
Tele hone Email address D I Demolition
4.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
IIIC Company Name or HIC Registrant Name
No.mrd Street - Email address
Ci /Town State ZIP Telephone
SECTION 6:WORKERS'.COMPENSATION INSURANCE 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 permiL
Signed Affidavit Attached? Yes ..........O No...........13
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED.WHEM f,'
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT'
1,as Owner of the subject property,hereby outhorim
t9 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.
Print Owner's or Authoriz r g Vs Nome nic Signature) Date
NOTES:
1. An Owner who obtm a uilding 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 W have access to the arbitration
—-- —
program or guaranty fund under M.G.L.c. I42A.Othcr--•—,mportanl information onlhe H1Cl'rogmm can a to`umtat--— - -- --
www mnss.eov:'oca Information on the Construction Supervisor License can be found at www.mass.eovtdns
2. When substantial work is planned,provide the information below:
'rota)floor area(sq. ft.) N (including garage,finished basemeatlattics,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
J. "Total Project Square Footage"may besubstituted far"Total Project Cost"
CITY OF SALEA MASSAC HUSEM
Buy. mDErAimEm
120 WASJ•M4MCKSUM,32D FLOOR
UL(978)7459595.
PAX(978)740-9846
KIIv18ERLEYDRISQ7LL
MAYOR 7)MUMST.i'EW
DnaCrCitoppLaucpRamm/BugDnccamwmcmm
Construction Deib& 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 coo, S 54; Building Permit R 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) g tp I n i3 A r RC2(,
The debris will be disposed of in:
VV �Z) c Srna SG (�
(name of facility)
(address of facility)
Signature of applicant
Date
L
a
CITY OF SALEM, MASSACHUSE TTS
' BUILDING DEPARTMENT'
120 WASHINGTON STREET,3"DFLOOR
TEL. (978)745-9595
KIMBERLEYDRISCOLL FAX(978)740-9846
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPE RTY/B UILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date r( 12-6 / 7_0Gr/_S I
Job Location
Home Owner Address '/ I /�� d L v ln1 �s K-u-<_
Present Mailing Address l I l_C�!�yien 1� �� 14-V-f_
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 SIG NATUK" :��7 �_"__�7
APPROVAL OF BUILDING INSPECTOR