8 MILK ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
•,cif Massachusetts State Building Code, 780 CMR, 7"edition
Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Fmni/l-Dive/ling
This Section For Oficial Use Only
Building Permit Number: Date Applied:
Signature:
Building Commissioner/inspector kfBuildings Date --T
SECTION I:SITE INFORMATION
LI Property Address: 1.2 Assessors Map& Parcel Numbers
Nll t d ;e
I.I a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L a 44,§54) L7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: Outside Flood Zone?
Check if yesO Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.i Owner of Record: "
PYl�en
Na I(Print) Address for Service:
IM)A)AA {a qla 141 21l8"
Signa ure Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs: Official Use Only
Labor and Materials y
1. Building S 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier�x
3. Plumbing S 2. Other Fees: S /
4. Mechanical (HVAC) S List: Ar,
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No. Check Amount Cash Amount:
6.Total Project Cost: Sj-X i0i WD ❑ — —
fi� 7t Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Ngme of CSL-Holder List CSL Type(sce below)
T Description
Address U Unrestricted(up to 35.000 Cu.Ft.
R Restricted 1&2 Famil Dwcllin -
Signature M Mmnry Only
RC Residential Roofing Covering
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 Affidavit Attached? Yes..._.....❑ No........... 0
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
` ' ^ SECTION 7b:OWNER!OR AUTHORIZED AGENT DECLARATION
A�
) ,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.
+� T N Ls
Print Name MIM \
Signature of Own&or Authorized Agent Date l I
(Signed under the pains and penalties of perjury) .
NOTES:
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.O.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I0.116 and I I0.115, 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 ofcooling system Enclosed Open
3. `Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF S.UY.M
PUBLIC PROPERTY
DEPARTMENT
IUfOEaIiY N".-n�
MAYOR 130 WMMNGTON S17aiT•SALOL MAUADWUrM 01970
Tm-97&743i9S"•FAx.973.740-9aN
HOMEOWNER LICENSE EXEMPTION
Please Priet 1
Date 4- 1-07
Job Location
Home Owner Address Fs Udt � f
Home Owner Telephone `('1 r -7 4l 2k
Present Mailing Address b M,td.i_ S1-
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
hire who.does not possess a license,provided that the owner acts as supervisor.
DEFINMON 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 dwellin& 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 shaU not be considered a homeowner. Such
-homeowner"shall submit to the Building Official,on a fora 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 '1TWhon procedures and requirements and that he/she
will comply with said procedure And requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code
I
CITY OF SALEM
s
PUBLIC PROPRERTY
DEPARTMENT
IJ: A \,+I h+ �N S I IU.Ir • SAII M. \Lhiv .,. ; .I'+ _
'III:')'8-'aS-);'S • I \s:'i7N '4}- 9.{Jig
Construction Debris Disposal Affidavit
(rcyuired I'm all demolition and renovation work)
In accordance Kith the sixth edition of the State Building Code, 780 CNIR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit N 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
I11. S 150A.
The debris will be transported by:
S ecteA c lteacfa av 4eA �-c& ' cv.A-t cU rL'r w-�t (a.e rempued
(name of hauler) _ L . kv
The debris will be disposed of in
(name of facility)
(address ul'I'acilily)
�Igualurc of permit.Ipplicant
dale