14 WINTER ST - BUILDING INSPECTION (2) Oe
1^ The Commonwealth of MassachusettsTY.SOF 1 S
``1 1 Board of Building Regulations and Standards I0; r i ',-'
W
116PEC S�dLElvl
--� Massachusetts State Building Code, 780 CMR Revised,Nur 2011 b
Building Permit Application To Construct, Repair, Renovate Or Demolish OV 25 P
One-or Two-Family Dwelling
This Section FOcOIRcial Use Only
\n lluilding Permit Number: Date. pplied:
-Building Oliicial(Print Name). - - : Signatures: '. Date
SECTION It SITE INFOILMATION'
I.I Propert�Address: 11 Assessors Map&Parcel Number
JA[infer Wit
tl.la this an acce ted street?yes X noM1tap Nwnber Parcel Numbar
on)ng Information: IA Property Dimensions:
Zoning District ; .. - Proposed Use - Lot Area(sq N) - Frontage(It)
I.5 Building Setbacks(R) .
Front Yard $iJe Yaids - Rear Yard
ReyuireJ Pro -
Required Provided- Required Provided
Provided
udnl 'Req
1.6W terSupply:(M.G.L c.J0,§5d) 1.7 Flood Zone Informallon: 1.8 Sewage Dbposal System:
Public O Private O. Zone: _ Outside Flood Zone? Municipal O On site disposal system- O
Check If :esO.
SECTION I: PROP6R1 Y,OWNERSHiPs '
2.1 Owners of oCd' Sa
Im ,�Q �vnflrl0t"f'�+
l�tlrrue(Print) - - Q City,State,ZIP
14w,t;}er streat - - ss3a )3os F33 ntw�•�
No.and Street Telephone Email AdJnss
SECTION 31:DESCRIPTION OF PROPOSED 1VORK3(check all that apply)`
New Construction O Existing Building E owner-occupied O Repairs(s) CI 1 Alterrtion(s) O Addition O
Demolition l] Accessory Bldg.O Number of Units_ Other 0 Specify:
Brief Description of Proposed Work': e i
nClr t�: P,_.►�n_F�+n i t� 1 Pcd��c i c�"rP-r-r-h'`^ t-S"t—'^'c-+u r-41 wb'C)5
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
hcm Labor and M1laterials -
I.Building S DDD. I. Building Permit Fee:S Indicate how fee is determined:
O Standard City/Town Application Fee
2.Electrical S I J2 0. O Total Project Cost.'(Item 6)x multiplier x
3. Plumbing no k 10 ptherFees: S It--\
d.Slcchanical (HVAC) S 5ZQOO List: �D6.
5.\lechanical (Fire 5 N)t4 u-rL Total All Fees:S
Su ression)
Check Na. Check Amount: Cash Amount:
G.Total Project Cost: 5 /5-6 00d.0 p Paid in Full ❑Ouislanding Balance Due:
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date-
Name of CSL Holder List CSL Type(see below)
No.;mJ Street TYpgDescription
. - _
U Unrestricted(Buildings Lip-to 35,000 cu. Il.
R Restricted 1&2 Family Dwelling
City/rown,State,ZIP M Masonry
RC Roaring Covering
WS Window and Sidling
SF Solid Fuel Burning Appliances
I I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
IIIC Company Name or HIC Registrant Name
No.mid Street Email address
City/Town.State ZIP Tel hone
SECTION 6:WORKERS,.COMPENSATION INSURANCE AFFIDAVIT(M:G.L c:152.1 2$C(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 ..........I] No...........O
SECTION 7m:OWNER AUTHORIZATION TO BE.COMPLETED.WHEN•
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING.PERMIT,
1,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 711:OWNEW 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' s app icatii rue and accurate to the best of my knowledge and understanding.
1 /�/2—f_ /5�
Print Owner's or Amhori A •at's Name(Electronic Signature) Date
NOTES:
1. An Owner who obt ' s 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 gg have access to the arbitration
program or guaranty fund under M.G.L.c. I a2A.Other importtanitinformatwn oniheHTC-Program can e-(amd—it —"
www m:us.eov;'oca Information on the Construction Supervisor License can be found at ww+v.nass.eovtdns
2. When substantial work is planned,provide the information below:
'rotal floor area(sq. R.) 'r (including garage, finished basement/attics,decks or porch)
Gross living area(sq. 11.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
type of healing system Number of decks/porches
Type ofcoolingsystem Enclosed Open
3. "Total Project Square Footage'may be substituted 1'or"Total Project Cost"
° QTY OF SALEM, MASSACHUSETTS
5� ! BUILDING DEPARTMENT
y_m s✓ 120 WASHINGTON STREET,3RD FLooR
TEL. (978) 745-9595
FAX(978)740-9846
KINMERLEYDRISCOLL
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date y \
Job Location 7 wt^In r Sf��2 % S4 )2-iK. l� A OI
Home Owner Address SL -�
Present Mailing Address Sill�
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
K1
APPROVAL OF BUILDING INSPECTOR
Q,Ty OF SALEg MASSAaimm
Bun.DnacDEPARmEw
120 WASmNGmgSTREET YDFLocR
IkL(978)745.9595.
PAX(978)740.9846
%IIvIBERLEYDRISOOLt
MAYOR THOMAS STREW
DIRECTOR orFaRucpxom TY/BLimmoom issio ER
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 c40, S 54; Building Permit fl 6 is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The�debris will be transported by:
(name of hauler)
The debris will be disposed of in:
cc)ho . A4
(name of facility)
(address of facility)
Signature applicant
//�25�
Date