131 BRIDGE ST - BUILDING INSPECTION (7) MET
! The Commonwealth of Massachu t tafi(� � CITY OF
Board of Building Regulations'!"- SALEM
Massachusetts State Building Code,780 CMR p 14, 2w Revised Mar 2011
Building Permit Application To Construct,RepaSt tehAaAr Demolish a
T One-or Two-Family Dwelling
This S,ectjon For Official"WeOnly
� Building permit;igrrmiier:, Date Applied:
t 6 D
v Building QfHe (Print Name) Dot
t SECT[ONi l:SITE 1NFORMA`TIDN
1.1 Prop Address: 1.2 Assessors Map&Parcel Numbers
I no
Ma
p Number
Parcel N mbu
l.la Is this an acce street. yes
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(it)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rest 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:
Zone: _ outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Cbeckifyes❑ _
SECTIO 2 PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Name(Print City,State ZIP t
ll
b�I � ( � �T b!S P tr1 p, � rvtnc�t l o�o1-n
No.and Street Telephone Email Address
SECTION&DESCRIPTION:OF PROPOSED WORK2(bheck all that apply)
New Construction❑ ❑ Owner-Occupied ❑Existing Building Repairs(s) Qr3 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ I Other. ❑ Specify:
Brief Description of Propqsed Work 2-
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only .
Item (Labor and Materials
1.Building $ 1• Bulkling Permit Fee;$ Indicate how fee is determine(
❑Standard Cityfrown Application Pee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ �`T
4.Mechanical (HVAC) $ List !>
5.Mechanical (Ftre $ Total All Fees:$
Su ession
,�/� Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ I vo ❑paid in Full ❑Outsiaa Balance Due: .
1�Pt �CYO Tb �
SECTION 5: CONSTRUenOiv SERVICES
5.1 Construction SupervisorLicense`(CSL)f_1 I
License Number Expiration Date
Name ofCSL Holder
List CSL Type(see below)
No.and Street T1Pe 'fit
U Unrestricted up to 35,000 cu.ft.
R Restricted 1&2 Family
City/rown,State,ZIP M Masonry
RC Roofing Covering
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
Ci /Town State ZIP Telephone
SECTION 6:WORKERS-COMPENSATION HNSUIIANCE AFEIDANi T(M.GI-c.152.§ 25C(46))
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 7ae OWNER AUTHORIZATION TO BE COA4P1E70)WHEN
OWNE,R'S NT OR CONTRACTOR
APPIMS FORFi . Inks 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!QWNEW OR AUTHOMED 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.
Priril Owner s or u onze gent's dro ' 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
w.aw.mass.ggy6m Information on the Construction Supervisor License can be found at m2nLmass. ovg /dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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'
CITY OF SALEM, MASSACMETTS
j" vb R BUILDING DEPARTMENT
..` 5 _ r✓r` 120 WASHNGTON STREET,3N0 FLOOR
TEL. (978) 745-9595
FAX(978)740-9946
KIMBERLEY DRISCDLL
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMNIISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT: /
Date 9 — 3pp®
Job Location 1 -2 p)�—' <A
Home Owner Address Q� ) l 1
l4 - c ��-2 -
Present Mailing Address 6&iYt/CQ
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.
I
HOMEOWNER'S SIGNATURE CLAA LAA/
APPROVAL OF BUILDING INSPECTOR
O yOF SALEM, MASSACKEEM
' BiatMDBPAJMdW
120WA9MV7MSMMffTOJ=ROCR
113�(q78 7*5-9595.
Fi►7C 740 9816
KRAI RIEYDRISQ7LI
MAYOR MOMASSTPB3M
Dnmc7MCFPLMUCMOFER!FY/BUMDMbDMkUg3CNM
Construction Debris Dispos&Affl* it
(required for all demolition and,.renovation work]
in accordance with the sixth edition of the State Building Cie, 780 MR, Section 111.5 Debris,
and the provisions of MGL c4Q S 54; Building Permit 8 is issued with the
condition that the debris resulting from this work shall be disposed of in a properly Ikaensed
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:
(name of facility)
(address of facility)
\ e
Signature of i`hcaht
Date