0005 MAPLE STREET - BPA-16-1081 2T0a c(c K092
The Commonwealth of Massachusetts '; '
Board of Building Regulations and Standards FRY �' V5
Massachusetts State Building Code,780 CMR Revised Mar2011
Building Permit Application To Construct,Repair,Renovate Or DenUMSEP 2 1 A 11: 24
One-or Two-Family Dwelling
T Srn For Use ,
Building Pnaarit:Ntrmber, : Date',. plied: / /
Gl5eial(Prnt e) 8>gaahae
_ SECT70I�i-1:$lTE RMATItIN
1 1.1 Property Address: 12 Assessors Map&Parcel Numbers
h'(_l y MAOG E S7'
1r I.la Is this an accepted street?yes_ no Map Number Parcel Number
I 1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided RegaireA 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 C2 On site disposal system 13Public 13 Private❑ Check if yesO
SEtTION2: PROPERTYOWNERSIi#Pt
1 - 2.1 Ownera b Recor k. SGr r 4 /`7� Ol 97a
X Name(Print) City,State,ZlP s S 3 S'17 "''4•/,C
No.and Street Telephone Email Address
SECTION 3:DESCRIPTIOpt OF PROPOSED WORW(check all tbat apply)
New Construction E3 Existing Building 13 Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work :
Rermovr
SECTION 4:ESTIMATED CgNSTBUCI'ION COSTS
Estimated Costs: Official use Only
Item (Labor and Materials
1.Building $ 1 Badding Permit Pee:$ Indicate hots fee is determined;
O Standard City/Town Application Fee
2.Electrical $ [1 Total Project Cost'(Item 6)x muttil Har x
3.Plumbing $ 2. Other Fees:
Ast-
4.Mechanical (HVAC) $ CJ
5.Mechanical (Fire $ Toml Ali Fees:$
Suppression)
Check No. —Check Amount: Cash Amount; .
6.Total PrPle t-Cost: $ ��Od p laidI.i( ❑Outstanding Balance Due:
R/zq Mr�t�� +4 , C)
SECTIO". COl STItUt rloN SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type
U Unrestricted(Buildings u to 35 000 w.R
R Restricted)&2F Dwe
City1rown,State,ZIP M masonry
RC Roo Covering
WS Window and Si
SF Solid Fuel Burning Appliances
I Insulation
Te] hone Email address D Demolition
5.2 Registered Home Improvement Contractor(RIC)
BIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
Ci /town State ZIP Tel Noce
SECTION tit WDRIMW COMPENS ATI4#N PWURANCE AFFIDAVIT(ALG.L f.152.§ 25C(o)
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...........O
SECTMN 7a OWNER AUTHbRIZA Tb BE COMIPLETED®6'HFNI
SYNEIt C OR_ >F nn H1G _
1,as Owner of the subject property,hereby authorize J o k" aJ , SS,
to act on my behalf,in all matters relative to work authorized by this building permit application.
Priv vner's Name(Electronic Signature) Date
SECTION 7b:OWNEV OR AUTHORIZED AGENT DECLARATION ,
By entering my name below,I hereby attest under the pains and penalties of pequry 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
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
MM.mass.eov,'oca Information on the Construction Supervisor License can be found at wUMass.eov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halVbaths
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, MASSAaiUSE TTS
BUILDING DEPARTMENT'
120 WASF]INGTONSTREET,3ft0FLOOR
ISL.(978)745-9595
KIMBERLEYDRISCOLL FAX(978)740-9846
MAYOR THOMAS ST.PIERRE
DIREGTOROFPUBLICPROPERTY/BUILDING COA&ffSSIOMR
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT.,
Date
Job Location
vG f
Home Owner Address 5 � /�/� S • , s'4 /+•.., /'i/f O/ S 7-6'
Present Mailing Address o/!. 7G'
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 SIGNATURE
APPROVAL OF BUILDING INS
CTO
OnCFSALEA MASSAMSETT,
BMMW DBPAADWrr
120w.► vsnWs3D1+LoM
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$lAeERiLP ,
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Dnac,7m crPtzLi&wAnwTAnvmwa maa
Construction Debris Disposa/Affidavit
(required for-all demolition and,.renovation work)
in accordance with the sbM edition of the State Building Code, 780 CMR, Secdon 111.5 Debri&
and the proWsioms of MGL coq S S4; &i hft Permit# Is Issued with the
condition dW the debris reSUIft from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111,S 1SQA.
The debris will be transported by.
�} Mhj2hL '6hf�R �2 �S�s
(name of hauler)
The debris will be disposed of in:
y 05
(name of facilfty)
(address of facility)
ignature of applicant
-2- 2-
Date