37 BEAVER ST - BPA-15-304 2ND FL BATH The Commonwealth ofMassachusettslNdSPECTIONAL SE rVICEO'Y OF
i Board of Building Regulations and Standar s SALEM
Massachusetts State Building Code, 780 CNIpRpIS E�pppp e a ,4/ar 2011
tdU 'Dd nAit � L
Building Permit Application To Construct, Repair, Renova r t h :i'
QOne-or Tivo-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date ApplI d:
_ r3Zo!nIng
ial(Print N;une). -'.-; Signature Date
SECTION 1:SITE INFORSIATION`
L2 Assessors blop&Parcel Numbers
ccepted street?yes noM1lap Number Parcel Number
Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sy R) frontage(It)
1.5 Building Setbacks(it)
Front Yard Side Yams Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(bl.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 Cl
Check if yesCl
SECTION2: PROPERTY OWNERSHIP,`
2.1 wnert of Record: 37 G��ir. s
/y1 tfA(L� KAAJ '
N me(Print) City,State,ZIP
em (-A A, G o 978-7y5-'af1y6 -®'
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building ClOwner-Occupied ❑ Repairs(s) ClAlteration(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work'-:
Of )
SECTION 4: ESTIb1ATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building $ lot j p d 1• Building Permit fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S 3 51v ❑Total Project Cost.'(Item 6)x multiplier s
3. Plumbing S 11�ell Q P Qther Fees: S
4.Mechanical (FIVAC) S List:
5. Mechanical (Fire $ 'rotal All Fees:$
Su ression)
Cheek No._Check Amount: Cash Amount:_
G. 'fotal Project Cust: S /61 UCU ❑Paid imFup ❑Outstanding Valance Dun:
�.� q/ zz
SECTION 5: CONSTRUCTION SERVICES r
5.1 Construction Supervisor License(CSL)
•• License Number Expiration Date
Name of CSL Holder
List CSL'fype(see below)
No. and Sued Typa. - : . Description
U I Unrestricted Duildin it to 35,000 cu. It.
JRC
Restricted I&2 FamilyDwelling
Cityltmvn,State,ZIP Masonry
Roofin Coverin Window andSidin Solid Fuel Burning Appliances
Insulation
Tele hone Email address Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
f 11C Company Name or HIC Registrant Name
No.mid Street Email address
City/Town, State ZIP Telephone
SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G.I«c.ISL I M(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...........O
SECTION 74.OWNER AUTHORIZATION,TO BE-COMPLETED WHEN'
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
[,as Owner of the subject property,hereby authorize Sh2O\Ae Seat :AngNVMyiiJ C
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
K,rtri%cy k ays-le- 5 1 i 5
Print Owner's Name(Electronic Signature) Date
SECTION 7b: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 in this application is true and accurate to the best of my knowledge and understanding.
Print Owi is oVAutho#1cd1 Agent's Name(Electronic Signature) ale
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 can be found at
www.mass.eov:'oca Information on the Construction Supervisor License can be Found at www.mas�
2. When substantial work is planned,provide the information below:
'total fluor area(sq. ft.) '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
'rypeorcoolingsystem Enclosed Open_
3. "Total Project Square Footage"may be substituted for"'total Project Cost"
1 i CITY OF SALE4 MASSAMUSE M
BLU DING DEPARTMENT
c58 120 WAsmNGTON STREET,3'm R.00R
nL(978)745-9595
KB6ERLEYDRISoC)LL FAX(978)740-9846
MAYOR THomm ST.PIERRE
DIRECTOROF"UCPROFERTY/BUIIAWGODM OSSIONER
Construction Debris Disposa/Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 MR, Section 111.5 Debris,
and the provisions of MGL c40, S S4; Building Permit fl q is 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 debriswill be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of of facility)
h
Signature of applicant
i 5- /5�
Date
QTY OF SALEM, MASSACHUSETTS
g BUILDING DEPARTMENT
120 WASHNGTON STREET 3"°FLOOR
TEL. (978)745-9595
FAX(978)740-9846
KIMBERLEY DRISCOLL
MAYOR TkomAS STTIERRE
DIRECTOROF PUBLIC PROPERTY/BUILDING COM USSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
�s Date �' 2
Job Location 3� sJQVC�i� `J
Home Owner Address
Present Mailing Address 3"1 ��°L
i
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
APPROVAL OF BUILDING INSPECTOR