146 MARLBOROUGH RD - BUILDING INSPECTION a The Commonwealth of Massachusetts
[)card of Building Regulations and Standards CITY
\vtm OF SALEM Massachusetts State Building Code, 730 CMR, 7 edition Revived Junuun•
Building Penn il,Application To Construct, Repair, Renovate Or Demolish a /. -1008
One-or Tnn nily Duelling
This S •tion Fk Otlicial Use Only
Building Permit Numbe . at App ed:q J
Signature: �twm
Building Commissioner/Inspector of Buildinb Date
SECTION I:SITE INFORMATION
1.1 Property Address: 1 1.2 Assessor Map& Parcel Number
ir/` KL sL�nre4o� �7 0� - '1n
L la Is this an accepted street?`yes no Map Number Parcel NumlP
1.3 Zoning Information: 1.4 Property Dimensions:
_?,-I �sre,� a� Ru cleN
Lomng,District Proposed Use -Lot Area(sq It) frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided llequired 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?Check❑ Private❑ Check if yes❑ Municipal❑ On site disposal system 11
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
c� nkk F P/4 MfX 16rao k [KCJ
Nari t) Address for Service: V.
")71 Sys- 0114
Signal Telephone
E ION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Constructio Existing Buildin Owner-Occupied Repairs(s) ❑ 1 Alteration(s) Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Lam, Brief Description of Proposed Work,:
A[)!q A r ps s rTLe- S k, Pit �
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Ofllcial Use Only
(Labor and Materials
1. Building S '3 J V 1. Building Permit Fee: $ Indicate how fie is determined:
El
City/Town Application Fee
2. Electrical S Q ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S O 2. Other Fees: S /�/6,�
4. Mechanical (I)VAC) S List: ` /
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No._Check Amount: Cash Amount
l/ 6. Total Project Cost: S �t7b ❑Paid in Full ❑Outstanding Balance Due:
,r ti
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Dale
Name ul'CSI.-I[older list CSI.1'ypc(see below)
7'v Description
Address II Unrestricted(tip to 35,000 Cu. Ft.)
It Restricted 1&2 Family Ihvellin
Signature NJ Masonry Only
RC Residential Routing Covering
Telephone WS Residential Window and Siding
DU Residential Solid Fuel Burning Appliance Installation
Residential Demolition
5,2 Registered Home Improvement Contractor(HIC)
I IIC 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
khf L^ �J c— _ �- as Owner of the subject property hereby
authorize 1e- to act on my behalf,in all matters
relatie o work authorized this building permit application.
Si atur f Owner Date
SEC N 7b:OWNERI OR AUTHORIZED AGENT D CLARATION
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 (late
(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(111C)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 1.12A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 730 CMR Regulations 110.116 and I IO.R5,respectively.
2. When substantial work is planned,provide the information below:
Total flours area(Sq.Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) flabitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half baths
Type of heating system Number of decks/porches
Type ofcoofing system Enclosed Open
3. "Total Project Square Footage"may he substituted for"Total Project Cost"
.4
CITY OF S.U.E.NI, ISL-kss kcHUSETTS
3U DtvG DEPARTMENT
130 WASHLNGTON STREET, 3"FLOOR
0 TEL (978) 745-9595
FAX(978) 740-9846
KIJBERLEY DRLSCOLL
MAYOR THO-%Us ST.PmRRs
DIRECTOR OF PUBLIC PROPERTY/HCttDNG COMMISSIONER
Construction Debris Disposal Affidavit
(required 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# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defincd by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of inluln . 5
:
n
(name of facility)
(address of facility—
}.
signam o permit applican _
dale
kbnvlrJ�:
n
CITY OF S.ULDeI
PUBLIC PROPERTY
DEP RTNIENT
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%"VMTIL 9,11-745-9595 j;.4A 9?5.74&960
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HOMEOWNER LICENSE EXE.NPTION
PfeaN Ftlsit
Dats
job Loeatias V 4 Rel
Home Owmt Ad&vn /Y e2 b?s U l
Homo Owost Telephone 7Y3" o
Preasd Mallin/Addsae /YG M a rL.La roux
The current exemption o[-Homeowners"was extended to include owner-occupied
dwellings of two Units at leas and to allow such homemwners to engage an individual for
him whodoes mt possess a tieensst provided that the owner acts as supasvises.
DEFlNMON OF HOMEOWNER
Person(s)who owns a parcel of land on which ha/sbe resides or intends to reside,on
which there h6 or is intended to bs;a one or two family,dwelling attached or detached
structures accessory to such use and/or farm st;ucttues. 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 wader the Building
Permit.
The undersigned "homeowner"assumes responsibility for complianee with the State
Building Code and other applicable by-laws and reguladomi.
The undersigned "homeowner"certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
.vill comply with said procedures and 'rem
HOMEOWNERS SIGNATURE T R
XPPROVAL OF BUILDING Di
SPEC
See other side for state code