12 HARTFORD ST - BUILDING INSPECTION ld� ,
The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
taf� Massachusetts State Building Code, 780 CMR. 7"edition
Building Dept
Building Permit Appli ion To Construct. Repair, Renovate Or Demolish a
O re- or Two-Fumill•Dwelling
This Section For Official Use Only
Building Permit Num r. Date Applied: /_' h
Signature: Y �• d
Buddin Co issioner s or of Buildings Date
SECTION 1: SITE INFORMATION
1.1111 party Addre : 1.2 Assessors Map& Parcel Numbers
/2 S .
1.1 a is this; accepted street7 yes_ no_ Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
7SUpply:
Provided Required Provided Required Provided
1. M.O.L c.40,I54) 1.7 Flood Zone Information: 1.8Sewage Disposal System:
Zone: Outside Flood Zone? Municipal Itz On site disposal system ❑
Pu ❑ Check if es0�
SECTION 2: PROPERTY OWNERSHIP'
2. rdt�•
�Gr�. Tiu✓�.-7 XJl
Name int) Address or Service:
i Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) Erl Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work': lee r6• ; 9112.
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
1. Building S COO 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
S. .Mechanical (Fire S Total All Fees: S
Suppression)
Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
• • License Numhr Expiration Date
Ngnte of CSL Hylder List CSL Type(,cc below)
Address REDResildential
Descn tion
tricted u to 35,000 Cu. Ft.)
cted 1&2 Family Dwelbn
Signature Onl
ntial Roofing Covering
Telephone ntial Window and Siding
Reside— Sobel Fuel Bumin A liance Installation
al 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. 152.4 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........... C3
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 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.
Signature of Owner Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf/,/ .
Print
Signat re o ner or A orized Agent Date
(Signed under the pains and penalties of perjury)
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 @yL 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 1 IO.R6 and 110.RS, respectively.
2. When substantial work is planned,provide the information below:
Total floors 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 SALEM, 2ANSSACHI:SETTS
BUILDING DEPARTMENT
ME.NT
p 120 WASHINGTON STREET, iso FLOOR
arj TEL (978) 745-9595
F.*.x(978) 740-9846
KINiBERIEY DRISCOLL
,MAYOR THo.%w ST.PIERRS
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG CONMITSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibiv
Mattie: (Busim�Organizationulndividual): _ l' c �A•✓ '�/
Address: / 2S 4 .
City/State/Zip: `Sa ``e� 11,4 691 f 70 Phone
Are you an employer?Check the appropriate box.
Type of project(required):
1.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet, t 7• ❑ Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers'comp.insurance. 9• ❑ Building addition
[No workers'comp, insurance S. ❑ We are a corporation and its
Eel
officers have exercised their 10.C1 Electrical repairs or additions
3.E I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers'comp. C. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. [No workers' �C
13.[✓TOther
comp. insurance required.)
Any applicant that checks box#I must also fill uut the sectiuo below showing their worked compensation policy mlonmation.
'I Lxrwownen who submit this affidavit indicating they ate doing all work and then him outside contmetws most submit a new affidavit indicating such.
=Cuntm fors that cheek this box most attached an additional ohm,showing the nome of the soh-emmacton,and their workers,e,mp.policy infantution.
/am an employer that is providing workers'compensation lnsuraace for my employees. Below is the policy and Job site
information. car
Insurance Company Name:
Policy#or Self-ins. Lic.#: Expiration Date:
Job Site Address: City/Staw/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
investigations ol'the DIA for insurance coverage verification.
/do hereby err der the pans nd putalt/es ojperJury that the rnjarmotion provided above is true and correcs
/•G gate:
Phone
OJjc•ial use auly. Do tot write in that urea, to be cumpleted by city or town q Feint
City or'ruwn: __ __ Permit/Liccnse#
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3.City/town Clerk 4. Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person: _ Phone#:
CITY OF SALEM
=l �
PUBLIC PROPRERTY
'.I
III' 'I'8 '44./:'ti I \S 'i'N '4 ,Sh.
Construction Debris Disposal .-Affidavit
(rcyuircd 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 c 40, S 54;
Building Permit h is issued with the condition that the debris resulting from
this work shall be disposed of in a pruperly licensed waste disposal facility as defined by MGL c
I 11, S I50A.
The debris will be transported by:
(name ut hauler)
I he debris will be disposed of in
i
(namr of Iaahly)
(:Iddre'<of I]cllilv)
Ic of Penn It applicant
'644'
Malt
:0 .,,. '..
CITY OF SME.tiI
PUBLIC PROPERTY
DEPARTMENT
WroR 130 W SMPAGWW STREET•SAteM,NAanoa'sam 01970
7XL 9'8.74S-95" • F.4Y.978-7409646
1101MEOWNER LICENSE EXEMPTION
Flew Pride/ p
Date
Job Location ��✓7 s /'� �l�t (�
Home Owner Address s 61 f 219
Home Owner Telephone 7�
Present Mailing Address z 3 I
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 as supervisor.
DEFINMON OF HOMEOWNER
Person(s) who owns a parcel of land on which helshe 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 O®cial,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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and
/requir ts.
HOMEOWNERS SIGNAMW
APPROVAL OF BUILDING 11 CTOR
See other side for state code