36 MARLBOROUGH RD - BUILDING INSPECTION t `
O� The Commonwealth of Massachusetts Town of
q / ►� Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 7ih edition Budding Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Family Duelling
This Section For Oficial Use Only
Building Permit Number: Date Applied:
Signature:
Buildi Com stoner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 P operty A dress: 11 / 1.2 Assessors Map& Parcel Numbers
r�6oYo
c Ma Number Parcel Number
I.I a Is this an accepted street'?yes JG no_ P
1.3 Zoning Information, n 2 1.4 Property Dimensions:
R 'I— — Lot Area(s It Frontage(ft)
Zoning District Proposed Use 9 )
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,554) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public W- Private❑ Check if es❑
SECTION 2: PROPERTY OWNERSHIP//' p
2.1 Jner'of Rrd:
,amt) Address for Service:
SigAat Iffie Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction O Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition qTAccessory Bldg.Cl Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work':= /!// n//z'//17, ✓� 2'
TO �lr rarr—
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building E I. Building Permit Fee: E Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing 5 2. Other Fees: E
l
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S Total All Fees: 5
Suppression)
n v� Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: S � 67 spy ❑ Paid in Full ❑ Outstanding Balance Due:
w
o, !
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
r.
' License Number Expiration Date
Ngme of CSL-Hplder List CSL Type(see 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.¢ 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 .......... 0 No........... O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
O W S T CONTRACTOR APPLIES FOR BUILDING PERMIT
I as Owner of the subject property hereby
auth n e to act on my behalf,in all matters
relative to work authorized by this building permit application.
Si nature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, ,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 Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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 I O.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 Syuare Footage"may be substituted for"Total Project Cost"
I
CITY OF SALEM
PUBLIC PROPERTY
DEPARTNiENT
Kl1n`:� N Nw•(ll
120 Ww9W4GT0N S72EEr•SA1Eh4\USLiOWSEM 01970
11L 979-715-9S9S# FAx.976.740.99.16
HOMEOWNER LICENSE EXE.MMON
Please Print
Date loo
Job Location cyc IV4 a d! S e A-112
Home Owner Address M
Home Owner Telephone 9 !7,-,6F—
Present
,lamPresent Mailing Address Sl9 16-7)6-
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
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 re srremenn
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SALEM
;,..�,, PUBLIC PRc�PRERTY
DEPAR"['.1vtENT
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Construction Debris Disposal Affidavit
(re(luiied Im all demolition and renovation \voik)
In accordance %%ith the sixth edition of the State Building Code, 780 CNIR section 1 1 1.5
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 he disposed of in a properly licensed waste disposal facility as defined by MGL c
I 11. S 150A.
The debris will be transported by:
-- (name of halter)
I lie debris will be disposed of in :
/_Va/ ,5/ r _
(namr of facility)
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