180 NORTH ST - BUILDING INSPECTION The Commonwealth of Massachusetts Town of
As� Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, T°edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Fmnily Dwelling
h This Section For Official Use Only
Building Permit Num Date Applied:
Signature:
Buildilig Commissioner/Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.2 Assessor Map Ar Parcel Numbers
1.1 aII Is this an accepted street')yes no_t(T Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage III)
1.5 Building Setbacks(ft)
Front 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 13On site disposal system ❑
Public Private❑ Check if yes❑
fto —
Dei
ECTION 2: PROPERTY OWNERSHIP'
I
Address for ervice:
9::74 �
Telephone
ION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
xisting Building❑ Owner-Occupied ❑ Repars(s) ❑ Alteration(s) ❑ Addition ❑ccessory Bldg. ❑ Number f Units Other ❑ Specify:
Brief Description of Proposed Work':
-2-AIF? EP-0017- 5`1129L
a�ITPRCZ Q r
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)X multiplier x
3. Plumbing $ 7 2. Other Fees: $ GW;S�
4. Mechanical (HVAC) $ — List:
5. Mechanical (Fire $ Total All Fees:$
Suppression)
/"��
Check No. _Check Amount: Cash Amount:
6. Total Project Cost: LZ-20
0 d) ❑Paid in Full ❑Outstanding Balance Due:
2
7
/ r
C44 JAI 4.6�4 rlffl�,p
y�
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
' License Number Expiration Date
Nome of CSL-Helder List CSL Type(see below)
'
Address ' Type Description
U Unrestricted(up to 35,000 Cu Ft.)
Signature R Restricted I&2 FamilyDwelling
M Masonry 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.§ 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
1, as Owner of the subject property hereby
authorize to act on my behalf, in all matters
relative to work authorizze� �ed 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 of r u
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 110.R6 and 110.115,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 of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF SMY. M
PUBLIC PROPERTY
DEPARTMENT
IU1Q`��Nlf/YV 1
MAYOR 1311 wARONGTOM ME=•SuaK MA9MO11.'MM 01970
TU-TW7 5.9595 9 FAX 979.74&M"
HOMEOWNER LICENSE E3MMPTION
Please Prl�
Date Z
)ob Location w
Horne Owner Addresa t<
Home Owner Telephone
Present Mailing Address t�
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 O>flciA on a fort 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 rouedures and requirements and that he/she
will comply with said procedures and r it ts.
HO,IEOWNERS SIGNATL,RE
APPROVAL OF BUILDING INS �ER
See other side for state code
=' CITY OF SALEM
a PUBLIC PROPRERTY
�,.. DEPAR"I''v1ENT
A,I II IB 1.1 r . _,I I m. �\1%'i I . :I'� '
III 'l-N '4 • 1'%Y: 778.'4.'6 L.
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance ith the sixth edition of the State Building Code, 7S0 CNIR section I 11.5
Debris, and the provisions of:NIGL c 40, S 54;
Building Permit N is issued with the condition that the debris resulting front
this work shall he disposed of in it properly licensed waste disposal Facility as defined by MGL c
I 11, S 150A.
The debris will be transported by:
(name of hauler)
I he debris will be disposed of in
(name of facility)
(address of I'acililv)
,le Ulu11111'
1111 appli nl
5
ale
ceT ; I o 411
GENERAL CONTRACTING
PROJECT
1 ' '„ 1