30 MEMORIAL DR - BPA 16-107 The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standarxrj}t' � `�P�� "ALEM
Massachusetts State Building Code,780 CMR Revised Mar 2011
Building Permit Application To Construct,Repair,Renovatle%r to h a 1 ; 5 h
O One-or 71vo-Family Dwelling
motion For.,:' 13�e .
Bttikhng Pew Nttlntier -1 Avow,
�Rnht 8 .
crrc�rl is sr o ►'>70
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
rV-,0 L
1.1a Is this an street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Area(s9 ft) Frontage(ft)
1.5 Building Setbacks(ft)
From 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 ❑
Public❑ Private❑ Check if es❑
STCTIO
. N4r PRbPEkTY4'9Vl?Eis1'�' • � '
2.1 ert of Record: to
YATa-M.csFa O gtz tErJ �it.rE� a
Name(Print) I
ayn
3p w�tinofLXAL 1� 7BI:1 -5`193 �obrta,.,[off .Sb-t�rv�
No.and Street 'telephone Email Address
SECTION&DESCRIPTIOIV.6F PROPOSED WORK (Week 39 thitt a@Ply)
New Construction❑ Existing Building❑ Owner.Occupied ❑ Repairs(s) ❑ Aheratlon(s) ❑ Addition ❑
Demolition O Accessory Bldg.❑ Number of Units Other ❑ Speeify:
Brief Description of Proposed WorV: 8L
WtJ p 41AL1. '. o
t.JT'N S
t�
SECTION 4:6S fIMATED CONSTRUCTION COBTS
Estimated Costs: OI,IYcial Use Only
item (Labor and Materials
1.Building $ 1. Bnildlag Permit Feet$_,�Indicate how fee is deteiminedi'
❑Standard City/`fowo.Apptication Foe
2.Electrical $ O Total Pudect Costs(item 6)x multiplier x
3.Plumbing $ 1 Comer Fees: $
4.Mechanical (HVAC) $ List:
S.Mechanical (Fire $ Total All Fees:$
g ion
Check No. Check Amount Cash Amount:
X� 6.Total Project Cost: $ a� 6� D Pfd Poll 13 Outstanding Balaace Due:
Cvs�zlau'rrQtN.svis
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder, r• + .
List CSL Type(see below)
No.and Street
U Unrestricted to 35,000 Cu.ft.
R Restricted l&2 Family
City/rown,State,21P M Masonry
RC Roofing Covering
WS Window and Siditut
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Strad Email address
Ci /town State ZiP Tel one
SEL9'IO1N
WOBitFi W COMPMATM DANCE AP MA,V; '�L"c.82.4 25CM
Workers Compensation Insurance affidavit must be completed and submitted with this application. Fafl re to provide
this affidavit will result in the denial of the Issuance of the building permit
Signed Affidavit Attached? Yes ..........O No...........O
la:OWNIR AUTfiftIzATON to a COWL==W,N
1,as Owner of the subject property,hereby authorize
my behalf,in all matters relative to work authorized by this building permit application.
y.,\- - �- ac) 44
Print(Tuner's Name(Electronic Signature) Date
SECTION 16:OWNERr OR AUTHOAIZEH AG1PdVT Dgs'CLARATIOPf , .
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
oin this application is true and accurate to the best of my knowledge and understanding.
1Q7'_
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.I.:c. 142A.Other important information on the HIC Program can be found at
%vww.mass.eov/oca Information on the Construction Supetvisor License can be found at www.mass.eov/dos
2. When substantial work is planned,provide the information below:
Total floor 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 beating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
,F CITY OF SALEM, MASSAC HUSE TTS
BUILDING DEPARTMENT'
;y 120 WASHINGTONSTREET,3POFLOOR
TEL (978)745-9595
J FAX(978)740-9846
KIMBERLEYDRISQ�LL.
MAYOR THOMAS STAERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING OD1YWSSIC)NER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date
lob Location 30 V-1E:r--\-0Yt,-RA1L 4DyL Sjc)�%NA
Home Owner Address 3 O rnE>rv\.p T A lvN)4\
I
Present Mailing Address
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 U �
APPROVAL OF BUILDING INSPECTOR
CITY AASSACHESE7T
BLVZMDEPAXnMff
120Wit4MWMSUW,3DA,OM
7>;L�47>�7�-9995.
$Il�BRiBYDtiL�L
MAYtaR 71issST.Pe
DjRsc mcrFtI MKvMY/BUMUMaaaafcM
Construction Debris DisposaiAffidvviit
(required forall demolition and,.renovation work)
in accordeme with the sbA edition of the State BuiMtng Code, M a^ Secoon iii.s Debre,
and the provisions of MGL coo,S 54; Building Pern*#i is issued with the
condition that the debris resulting from this wok sha0 be disposed of in a property licensed
waste deposit facility as defined by MGL c 111,s 151.
The debris will be transported by.
(name of hauler)
The debris will be disposed of in:
(name of facifity)
(address of facility)
Signature of applicant
9-- a0 — Lc�
Date