0006 CHARLES STREET - BPA-13-1030 ��O
V' The Commonwealth of kMassaehusett arys
� OF
Board of Building Regulations and Standards LRevisedXfar2011
NI
�Yt Massachusetts State Building Code,730 C vIR EM
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Sect onForOfficial UseOnl
Building Permit Numberr Dafe'Applled;
Building Official(Print Name) $tgnature Date
SECTION I:SITE INFORNIATIOty.
,114 Property W ress: L2 Assessors Map& Parcel Numbers
�tia� s / r
L l a Is this an accepted street?yes—VI no Map Number Parcel Number
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 Rear Yard
Required Provided Required Provided Required Provided
Fand
upply:(M.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Private❑' Zone: _ Outside Flood Zone? Municipal Cl On site disposal system ❑
Check if es❑
L
) SEGTIONZ:; PROPERTlI'OWNERSHD?.f ec//�i 177S lft°�r �/�City,State,ZIP
'/Fs Sf/ePf �/li1 (0 83Z-227S �,,Telephone Email Address
SECTION 3: DESCRIPTION OF,PROPOSED.WORKV(check all.that apply'}
New Construction ❑ Existing Building Ef Owner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units 2 Other ❑ Specify:
Brief Description of Proposed Work3: aun sin ec 4 /1�.
SECTION 4: ESTINIATED'CONSTRUCTIOtN COSTS
Estimated Costs:
Item Official Use Only
Labor and Materials
1. Building $ I. Building Permit Fee:S' Indicate how fee is determined:
CI Standard.City/fusvn-Application Fee.'
2. Electrical $ ❑'total project Costa(Item 6)x multiplier x
3. Plumbing S 2. Other Fees:'$
1. Mechanical (EIV.\C) S
List: L
. Mechanic.il (Fire S ,rUO,t70
SnP ressiun) _ I'utal:\ll Fees:.S
-- Check No. Check Amount: __Cash Amount:
r -1'utal Project ('uiC S f 0 Paid in Pull 13 Outstnudim, Ilalartce I)[w:
r '
r �
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL I lolder List CSL Type(see below)
Type Description
No. and Street -
U Unrestricted Duildin s u to 33,000 cu. ft.
R Restricted 18t2 F;unil Dwellin
City/rown,State, ZIP M N'lason
RC Rotin Covcrin
WS Window and Sidin"
SF Solid Fuel nurning Appliances
I Insulation
1'ele hone Email address D Demolition
5.2 Registered Hone Improvement Contractor(1IIC)
HIC Registration Number Expiration Date
I IIC Company Nmne or IIIC Registrant Name
No.and Street Einail address
City/Town, State,'LIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152.1 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........... O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property,hereby authorize
to act on my behalf, in ail matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7h: 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 best of my knowledge and understanding,
_Ate, � 1 7
112
Print Owner's or Autlwrited Agent's Name(ElectronicSignature) Data
NOTES:
I. :\n Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(nut registered in the Hume Improvement Contractor(HIC) Program),will not have access to the arbitration
program or guaranty Lund under M.G.L. c. 142A. Other important information on the IIIC Program can be found at
www m:u:.atrv%uca Information on the Construction Supervisor Licensee. be Found at te-ww.mas,,g k Ll
2 When substantial work is planned,provide the information below:
Total flour area(sq. It.) —(including garage, tinislmd bnsenent/attics,decks or porch)
t1r0S; living area(S(l. ft.) Habitable rooln count —
Nnmbernftirapl.tecs__--------- Number ofbedrooms ---------_.._-----
Numhcr of bathroom; Nuutber of halEbatlis - --__—_--
- -------------- -
I'cpo of lwating Sy;tCm —_._-- Numher of Jack.,•,'porches _—____---
I)pe of eanliu� ;goon _..-_- Enclosed_-- _ t teen ---------— - -.
"['oral l'n q:rt lgki ua Foot.lge"in.ry he illb;nnil:J t u'[- cil l'rnjoit prat"
CITY OF SM N
PUBLIC PROPERTY
DEPART.. LENT
wren �>e w'�w�.�a,sts.sr. luaaa,.W�saowssm 01t1'0
ru
HOMEOWNER LICLNSB EXE.I�MPTI0t1
PWW "I
Data 3 // /,t
lobLoeados ��IGrIPS Oleel 0n/f
Home Owner Address
Homo Owner?elepbmo 9 ) 3 Z 7 2 7 s
Present Mailing Address
The current exemption o!"Homeowners"was extended to include owner-occupied
dwellings of two Units or less and to allows such homeowners to engsgs an individual for
him who dam not possess a license provided that the owner acts as supervisor.
DEFUMMON OF HOWOWNEA
Person(s) who owns a parcel of Land on which Wshe resides or intends to reside, on
which then i6 or is intended to be, a one or two family dw@l&& attnehed or detached
strueturee 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 OQlciA 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""Mores responsibility for compliance with the State
Building Code and other applicable by-laws and regulations
The undersigned "homeowner"certifies that hdshe undmunds the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
.Vila comply with said procedures and req
uir
ements
HOMEOWNERS SIGNATL'RB
.kPPROVAL OF WILDLVG LYSPECTOJR
See other tide far state code
I
_ ClTY OF S.1L.Em, Juus.1CHUSETTS
v
Bt:=LVG DEPARTNONT
120Cf/%3HLVGTON3T rzT, 3i°FLCOit
TEL (973) 745-9595
K1J[3ERL.EY ORJSCOLL Ft C(973) 7•10-9U1
AMA 11IO.%4UST.PIERRS
DfaECTOR OF PuaLIC PROPERTY/BCILOLVG CC-NWISSIONER
Construction Debris Disposal Aff7davit
(required for 311 demolition and renovation work)
In accordance with the sixdt edition of the State Building Code, 730 C' IR section l 1 I.S
Dcbris, and the provisions of rNfGL e 40, S 54;
Building Permit N 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 NfGL c
I11, S ISOA.
The debris will be transported by:
(name of haulw)
The duubris will bo disposed of in
1
_c-- (name at lacrliryQ)
(,ddros.t of ra.ilir�)
sib;uotnra o(pccmit applicant