4-6 ATLANTIC ST - BUILDING INSPECTION d
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The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY SALEM
Massachusetts State Building Code, 780 CMR dMar
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Family D,welling
This Section For .fficial Use Only
Building Permit Number Date Applied:!
Building Official(Print Name) - _'Signatur
SECTION I: SITEINFORNIATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
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1.1 a Is this an accepted street? yes ✓� no rvlap 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 a 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION2:, PROPERTY'OWNERSHDP'
2.1 Owner'of Record:
Wcsu l< tr0. >H4J-,, 8,46
Name(Print) ICity,State,ZIP
.q ATf1�T-(C- S'�-- 778 I LI 4 '7275
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK` check all that apply)
New Construction❑ Existing Building ❑ Owner-Occupied Repairs(s) 1W Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units 'l Other ❑ Specify:
Brief Description of Proposed Work': — slAztc RQe5-F
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SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
[rem Official Use Only, ,
Labor and iVlatcrials
I. Building S 000 I Buildlpg.PermitFee $ Indicate how fee is determined:
o. Electrical S ❑ Standard City(Town Application Fee
❑'Total Project C6sO,(Itern.6)x multiplier. x
3. Plumbing S 2 Other Fees: S
{, \-[echanical (EIV:\C) S List:
5. Mechanical (Fire
_Suppression) Total All Fees: .S
Check No. Check AmOUnt: Cash Amount:
6 l'ota 0 Paid in Fill ❑ Outstandin.
o Balance Due:
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License (CSL)
Licensz Number Expiraion Date
Name of CSL I-lolder
List CSL Type(see below)
No. and Street Type -. Description
U Unrestricted Buildings up to 35,000 cu. ft.)
_ R Restricted 1 R,2 Family Dwelling
City/Town, State, ZIP bI Masonr
RC Roofing Covering
WS Window and Siding
SF Solid Full Burning Appliances
I Insulation
'I'de hone Email address D Demolition
5.2 Registered Home Improvement Contractor(1IIC)
HIC Registration Number Expiration Date
HIC Company Name or IIIC 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 .......... 0 No ...........
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SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
[, as Owner of the subject property, hereby authorize
to act on my behalf, in at[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 application is true and accurate to the bqst of my knowledge and understanding.
dwa d K�wk. i s I.?
Print Owner's or Authorized Agent's Name(Electronf Signature) Date
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. I42A. Other important information on the II IC Program can be found at
www.mass.gov.-oca Information on the Construction Supervisor License can be found at www.muss.��r�lri
2. When substantial work is planned, provide the information below:
Total floor area(sq. rt.) _(including garage, finished basement/attics, decks or porch)
Gross living :uea(sq. 11.) _ Habitable room count
Number of tireplacc.s.-- Number of bedrooms - —
Numberofbathroonts _ Number ofhaltibaths _
Type of heating system -_ Number of decks/porches
Fypeof cooling sysluiu_ Enclosed Open
3 Total Project Square Footage" umy be substituted tbr''fn1:d Project Cost"
—
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CITY OF S<- F-.6%f, NL),S&kajuSETTS
� r BLAD4YG DEPARTNt&NT
l er+t 130 WASHINGTON STREET, 3" Roopt
TEL (978) 745-9595
KIMBERLEY DRISCOLL F.+x(978) 740-9846
AYOR TI.10.%W ST.PIMUM
DmECTOR OF PCBLIC PROPERTY/SMI)NIG CO%alISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work) T '
In accordance with the sixth edition of the State Building Code, 730 CMR section l l 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
I 11, S 150A.
The debris will be transported by:
No E
(name of hauler)
'['he debris will be disposed of in
(name of fact hty)
i
(address of facility—)
IN
signature ofpern applicant
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CITY OF S AI.E.M
PUBLIC PROPERTY
DEPARniENT
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HOMEOWNER LIMNSE EXE.M"10M
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Job Laeados TL C- S C S?!
Home Ownsr Address s to
Home Owner Telepban* 7LN- 7Z95
presedMaMoAddrees 4 Ar1W�`ttc- S r-
Ths current exemption of"Homeowners"was extended to include owner-occupied
dweWnge of two Units or lean and to allow such homeowners to engage an individual for
him who does not possess a liemse provided that the owner acts as mWervisor.
DE lNM0N OF HOMEOWNER
Persons) who owns a parcel of land on which bdshe resides or intender to re dde4 on
which there is, or is intended to be,a ons or two family dwelling, attached or detached
etrucnua accessory to such use arWor 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 0Oloi4 on a form acceptable to the Building
Official, that he✓she be responsible for all such wort performed under the Building
Permit.
The undersigned "homeowner'assumes responsibility for compliance with the State
Building Code and other applicable by-laws and relulationp.
The undenigned "homeowner"certifies that he/she undentands the City of Salem
Building Department minimum inspection procedures and requirements and that hdshe
mill comply with said procedures and requir rnM
H0MEOWNERS SIGNATURE
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APPROVAL OF WILDING NSPECTOR
See other side for state cod*