105 F DERBY ST - BUILDING INSPECTION JACKET / '' The Commonwealth of Massachusetts
} Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 730 CMR, 7"edition OF SALEM Rrri.xedhmu�try
Building Permit Application To Construct, Repair, Renovate Or Demolish a l• 'i)ON
On or Tm•o-Family Dwelling
Tlis Section For Official a Only
Building Permit Nu ber: Dat pplied:
Signature:
I ng om ssmner Ins •to uildings Date
CTION 1:SITE INFORMATION
LI Property Address: 1.2 Assessors Map& Parcel Numbers
F De-f-b
L l a 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 It) - Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Require) 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 Pluod Zone'?Public❑ Private❑ C heck if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
r5w"lN S ;ll; /os F berry sa .
Name(Print) Address for Service:
979 376 89 9
Signature Telephone
S CTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied 13Repairs(s) ❑ Alteration(s) 13 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Beef escription of Proposed Work': w a o i 17-e—(41np o�Gttk i�� �t,�d /9VZ—J s!' !ice v
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
` (Labor and Materials)
I. Building S 3 U a I. Building Permit Fee:S Indicate how tee is determined:
❑Standard City/Town Application Fee j
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S �� Q 2. Other Fees: S �-
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire
Total All Fees:S
Suppression)
Check No._Check Amount: Cash Amount:_
6.Total Project Cast: S 9 S� 13 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5,1 Licensed Construction Supervisor(CSL)
License Number lispimtiun Dale
Name of CSI.-I]older List CSL 1'vpe(see below)
OSFResidential
Description
Address stricted a to 35"00 C'u.FL)
icted Ibk2 Famil Uwcllin
Signature n Onl
s ["I Boutin Cuverin
I clephone ential Windmv and Sidin
Solid Fuel Burning Appliance Installation
U Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6: 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.
Si mature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
J ,as Owner or Authorized Agent hereby declare
that the statement4 and informatio the foregoing application are true and accurate,to the best of my knowledge and
behalf.
x Print Name // y3 /
Signature ol'Owner or uthori zed Agent Uate
Si n-d under the painsd penalties of er'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 nut 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 110.115, respectively.
?. When substantial work is planned,provide the information below:
Total floors area(Sy. Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sy. Ft.) Ilabitable 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 he substituted for"Total Project Cost"
CITY OF SALE.Nc
PUBLIC PROPERTY
DEPARTMENT
VAros �>owmurr rowlnear•
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TVA.9'&741959!9 F..L 97&746964
HOMEOWNER LICLNSE EXEMPTION
Pkw Print
Dare
Job Location /Os- P --
Home Owner Address Sti
Home Owner Telephone 1 7 F �1 7(0 e999,
Present Mailing Address <,ZA v/lL
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 who does not possess a license provided that the owner acts in supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which hatshe reside or intends to resider on
which them is, or is intended to be,a one or two family dwellinS 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 wort performed wader 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
will comply with said procedures and requir encs.
HOMEOWNERS SIGNATURE - _---
APPROVAL OF SUILDNG NSPECTOR
See other side for state code