77 PROCTOR ST - BUILDING INSPECTION (2) 'J �IC)s CK Sag
The Commonwealth of Massachusetts l `'�4
Board of Building Regulations and Standards" T `Vi OF
Massachusetts State Building Code,780 CMR SALEM
eulsed AGar 2011
(J Building Permit Application To Construct,Repair,Renovate(BbewiSh� !Pei
/e One-or Two-Family Dwelling
'-�. -.: -:e... . Ts,Seetiort For.Offtotal Use Only - .
t Building Petmlt.Numbei , Date liad
'�4—. %&3140
_ uuilding O a (Pntn NaFne) " Stgualme _ . . Date
SECTION 1:SM 17VFORIYIA PION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
Lin is this an accepted street?yes_y/ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Pro arty Dimensions:
3 d6
Zoning District Proposed Use Lot Arca 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 c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if es❑
SECTION2t PROPSRTYOWNER��tSI��iII't
2.7 Owner'of ReyyrO t YI S 54/t r
(Fn b11 t r
( Sl
Name Pring �- ��— City,State, T
7V'`6a0-?Ed& )Cisnvt. l2o�a��–ICe r�a>JtrJ.rl
No.end Street Telephone Email Address
SECTION 3:DESCRnn0N OF PROPOSED WORK;(oheck allthat apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) Alteration(s) O Addition ❑
Demolition Accessory Bldg.❑ 1 Number of Uxtits_� I Other ❑ Specify:
Brief Description of Proposed Worlrz: n 0 -6U ta f, n j) 11 lift
SECTION 4:ESTMATED CONSTRUCTION CO
Item Estimated Costs: Official iSse Only
(Labor and Materials
1.Building $ 5' pU-o 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ 13Standard City/fown Application Fee
O Total Project cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ r'
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Session $ Total All Fees:$
u r
Check No. Cheek Amount: Cash Amount:
6,Total Project Cost: $
1 { JOPaidinFull ❑Outstanding Balance Due: ..
e-7 0vh,15,�;cJ M lit q ( lam
SECTION 5 CONSTItUGTION SMVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder -+— -
List CSL Type(see below)
No.and Street
Tppe Desorlption
U I Unrestricted(Buildings up to 35,000 cu.ft.
R I Restricted l&2 Family Dwelling
Cityfrown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SFI Solid Fuel Burning Appliances
I I Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(RIC)
IRC Registration Number Expiration Date
HIC Company Name or IHC Registrant Name
No.and Street Email address
Ci /Town State ZIP Telephone
SECTION 6;WORKERS'COMPENSATION UMRANCE AFNTDAWT(ALGJ-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 72:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES VQA 131URI)ING 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.
Print Owner's Name(Electronic Signature) Date
SECTION 711bt OWNER'OR AUTHORIZED.AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Jcscr" ebb )C 9 6- i
Print Owner's or Autho' d Agent's Name(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hives 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 can be found at
�nvw.mass.eov,/oca Information on the Construction Supervisor License can be found at M2M.mass.eov/dns
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 heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
4 30 inch wide
Doorway to Windows
Doorway to
bedroom back hall '
Stove
Cabinets '` Microwave
3 ft
Cabinets Fridge Cabinets
6 ft 10 ft
a
Window
Sink
Cabinets
6 ft
Outside
wall
/#
Entrance from dining room
CfTYof SATS MMAa-ESET P.
BUMUMDEPAMMUff
i2o w ►saxi�r,5*'FLt�t
ML 745-9595.
KIINBERIZ'YDdiis�.
jyyty�j 7�i01r�SST.PJ131�
D=C=oFRMtICPROFwT/s
Construction Debris DisposaiAMOV t
(required forall demolition and,.renovation workj
in aaowdence with the sbA edition of the Siete Building Code, 780 CMR, section 111.5 Qebris;
and the moans of MGL c40,S 54, BLilding Permit It is issued with the
condition that the debris resulting from this work shah be disposed of in a property rkensed
waste deposit City as defined by MGL c 111,S 156h.
The debris will be
transported by:
Np,,
(nam fe oo hauler)
The debris will be disposed of in:
Accu c. Toqm t( 5i*()ri
(name of facility) -
�d
(address of facility)
Si ature of applicant
Date
r
CITY OF SALEM, MASSACHUSETTS
BUILDING DEPARTMENT
i+ 120 WASHINGTONSTREET,3"DFLOOR
TEL.(978)745-9595
FAX(978)740.9846
KRaERLEYDRISOOLL
MAYOR THOMAS ST.PIERRE
DIREGTOROFPUBLICPROPERTY/BUILDING CDMMISSIOMR.
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date G - 06 . / u
�Q.f
L \
Job Location -r7 jLzri� 4 (�f z
Home Owner Address 7 "7 foil' ree� -5ajepel
Present Mailing Address 7� &Cfvr '51'7 e-t t �)a l ew
The current exemption of"Homeowners"was extended to'inciude 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
i
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
APPROVAL OF BUILDING INSP OR