17 MALL ST - BUILDING INSPECTION The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 7ih edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a I
-F I' Duelling
This Secti in For Official Use Only
Building Permit Nu bee Date Applied: /
/Signature: 01111
JBuil in Com Issioner/Ins of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: U/9 y, 1.2 Assessors Map& Parcel Numbers
i 3 �/�c� s7
Ma Number Parcel Number
1.1 a Is this an accepted street'?yes_ no_ p
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
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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system 13ublic 13 Private❑ Check if es❑
SECTION 2: PROP RLOWNERSHIP'
2.1 Owner'of Record: �7- Ste.
QP nALAK 4 CN2/S DUNAI
Nam int) dress f'or ServicllJ�.— /3
ignature Telephone Y'
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s)" Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimate Costs: Official Use Only
Item Labor 4d Materials
1. Building b a,rj0 i 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing 5 2. Other Fees: E
4. Mechanical (HVAC) S List:
5. Mechanical (Fire 5 Total All Fees: E
Suppression)
Check No. _Check Amount: Cash Amount:_
6.. Total Project Cost: E 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) _
a License Number Expiration Date
Ngmc of CSL-Hplder Liu CSL Type(sec below)
Address Type Description
U Unrestricted(up to 35,000 Cu. Ft.)
Signature R Restricted 1&2 Family Dwelling
M Masonry Only
RC Residential RoofingCovering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D 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. 152.4 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 Afdavil Attached? Yes .......... ❑ No...........❑
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
y� SECTION 7b:OW/NEW OR AUTHORIZED AGENT DECLARATION
1, /J���✓�/� L. 'L2 ,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
behal
Print N e sC
Signatur 'of Owner or Authorized Agent Date
St ned under the pains and penalties of r"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 not 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 I O.R6 and I IO.RS, respectively.
2. When substantial work is planned, provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basemenUattics,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
,.• ,;y ,� PUBLIC PROPRERTY
DEPART"0ENT
�\ 'i'% V: r,L.
Construction Debris Disposal Affidavit
ociluiied liir all demolition :md reltovation work)
In accordance ith the sixth edition of the State Building Code, 780 CMR section I 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit K is issued with th ,condition that the debris resulting from
this work shall be disposed of in it properly licensed w ste disposal facility as defined by MGL c
I 11, S 150A.
The debris will be transported by:
(natne of hauler)
I he debris will be disposed of in :
(twine of IacuIJy)
I:uIJre�. of I]cllity)
a�nalw[ of p:nnit .Iphhcanl
,�a IC
_ f
CITY OF SA X. M
PUBLIC PROPERTY
DEPARTMENT
KJ NOL&L"0XISL w L
Vwraa
130w.mu7,c,-roN snasr•SuFx VtiuwaWsnT1s 01970
TEL 9'.L7ii9S"• t••..z 979-7.6&984
HOMEOWNER LICENSE EXEMPTION
Please Priet
Date /3/a
Job Location ��� Sr s�}Lz777 d7'J.9 o J g3tj
Home Owner Address
Home Owner Telephone GJ — — 6
Present Mailing Address s /Y1�4 e9 19
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.
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
Otlicial, 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 "homeownee'certifies that he/she _ rands the City of Salem
Building Department minimum inspection pros es and requirements and that he/she
will comply with said procedures and req ents.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code