B-19-1251 - 0033 BOW STREET - Building Permit The Commonwealth of Massachusetts
® Board of Building Regulations and Standards FOR
Massachusetts State Building Code,780 CMR MUNICIPALITY
USE
Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use.Only
Building Permit Number: Date Applied:
(2,C)CGS
Building Official(Print Name) r Signature Date
SECTION 1:SITE INFORMATION
1.1 Prope Address: 1.2 Assessors Map&Parcel Numbers
T?o w �r7-_C4
rv) 1.1 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 ft) 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 yes❑
SECTION 2: PROPERTY OWNERSHIP
2.1 Owner'of Reco
&I ) V_ c-)C4 w �
Name(Print) City,State,ZIP
No.and Street Te ep one Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work 2: / fti y
r
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical g ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ -��v ❑Paid in Full ❑Outstanding Balance Due:
I
L
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Coveriii
WS Window and Siding
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 Street Email address
City/Town,State ZIP 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
I,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 7b: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 ap 1' ion s true and accurate to the best of my knowledge and understanding.
// —
Print Owner's or uthorized ent's Name(Electronic Signature) Date
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.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.pov/dps
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"
i
E
CITY OF SALEK MASSAaiLSEM
Bu .Dm DEPARTb1Ew
120 WASHINGTON STREET,310 Rom
TEL(978)745-9595
FAX(978)MM46
KBEERLEY DRISOOLL
. . _ MAYOR,... THcmAs ST.PIERRE
DIRECTOR OI;PLJBLICPROPERTY/BI mmr-OOI MSSIOMR
Construction Debris Disposal Affidavit
(required for all demolition & renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR,Section 111.5 Debris,
and the provisions of MGL 00,S54;Building Permit# is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licenses
waste deposit facility as defined by MGL c 111,S150A.
The debris will be transported by:
(/UI
,jZ
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
(today's d e)
�+ CITY OF SALEA MASSAMUSEM
l e
BI;IQ. =DEPARTA ENf
120 WASHN MN STREET,3RD RDM
7kL(978)745-9595
KU BERLEYDRISOML FAX(978)740-9846
MAYOR 7HrMAS STTIERRE
DIRECTOR OF PUBllCPROPERTY/BUIIAING OOAmsslONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
II
DATE: I� /
JOB LOCATION
HOME OWNER ADDRESS: e3 al &I
PRESENT MAILING ADDRESS:
The current exemption of"Homeowners"was extended to include owner-occupied dwellings of two(2)units or less arld 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 own 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 access6ry 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 the 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 com ly with such procedures and requirements.
HOMEOWNER'S SIGNATUR
APPROVAL OF BUILDING INSPECTOR
Your Confirmation number is 20191107372923
Date of Confirmation:11/7/2019
NOTE:When paying by ACH(Checking)it will take two business days for the payment to be debited from your bank account.Your
account number is not verified until this payment is presented to your bank.They have the right to return this payment if unable to
process this transaction against your account.
Your request for payment(s)of$87.95 has been received and is subject to approval by your financial institution. No email was entered
so a confirmation was not sent.
Account Information Payment Information
Name: DANA DOOLEY = Payment Type: Credit Card
Note: QUICK PAY TRANSACTION Payer Name: DANA DOOLEY
Card Number: **************1611
Transaction Information
Transaction Quantity Amount Fee Payment Type
City of Salem-Inspectional Services 1 $84.00 $3.95 Credit Card
Building Permit
First Name:Dana
Last Name:Dooley
DBA/Company Name,if applicable:
Name of permitted/inspected property:
dedooley@zoho.com
Address of permitted/inspected
property:33 Bow Street -
Phone#:978-741-8662
Contact Email Address:
dedooley@zoho.com
Total:$87.95
{