57 DEARBORN STREET - BUILDING INSPECTION 4 32-p
,ram The Commonwealth of Massachusetts
—! Board of Building Regulations and Standards CITY OF
j Massachusetts State Building Code, 730 CIYIR SALENI
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Divelling
This SactionForOfficial Use Onl
Building Permit Numberr Date AppliedS` ?1Dl
! adding ficial(Punt ame) Sig Date
SECTION L•SITE INFORMATION
LL Property Address: 1.2 Assessors Map& Parcel Numbers
S'7 Deax bean
L l 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 tt) Frontage(it)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required: Provided
1.6 Water Supply:(M.O.L c.411,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑' Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if es❑
Sj CTION1.' PROP.kRT1G'OWNERSHIP< '.
1.
2.1 Ownert of Record:
1� Eti Cc�YZ'4 S.,lew. Mil aly,
Name(Print) City,State,ZIP
V OeaytIOM sd- d S0.�-SZi9 LCGO(LAYq_6A4A t_-CoM
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction❑ Existing Building)( Owner-Occupied Repairs(s) ❑ JAIteration(s)XI Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units i Other ❑ Specify:
Brief Description of Proposed Work": 4C"e,4
6e.Fw" (;,'IC1nu1 QVJ I,tn 1?`Q1W NG.t fvirJc drxr w [lP�!
r
SECTION 4: ESTI1NLkTED CONSTRUCTION COSTS-
Item Estimated Costs: OfBclot Use Only
Labor and Materials
1. Building g 3Spap 1..Building.Permit Feet S rhdicate how fee is determined:
a. Electrical $ ❑Standard.CityiTotynApplicationFee
LOCO ❑Total Project Costa(Item.6)x multiplier x
3. Plumbing > Li0<x) 2. OtherFees:•.S
1. M,.Chanical (It#�
List:
. Media nical (F
XSup pressiun) _ Ntal All Fees:.SCheck No. Check Amount: CushAuwuntFufal Project Cul 000
, � U Paid in Pall ❑Outstanding ISuLutca I)na:
or r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Gspiruion D;ne
Name of CSL I folder List CSL'rype(sue below)
rype Description
No. and Street
U Unrestricted Duildin s[in to 13,000 cu. ft.
R Restricted 1&2 Fa—il Dwellin
City/Town,State, ZIP hl Masonr
RC Rootin Coverin
WS Window and Sidin"
SF Solid Fuel Burning Appliances
I Insulation
l'ele hone Email address D Demolition
5.2 Registered Hone Improvement Contractor(HIC)
HIC Registration Number Expiration Date
I IIC 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,e. 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.
Jl / t IicFfn Corsw
PrmtOwi�NaAe(ElectronicSignature) Date
7SECTION 7h. OWNEW OR AUTHORIZED AGENT DECLARATION
enteringe below, I hereby attest under the pains and penalties of perjury that all of the information
lication is true and accurate to the best of my knowledge and understanding.
rnurieed A; ntb L ante( lectrumc Signature) Data
NOTES:
I. :u owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Houle Improvement Contractor(H[C) Program),will not have access to the arbitration
program or guaranty find under M.G.L. e. 142A. other important information on the HIC Program can be found at
w~v nrus.euv%oca Information on the Construction Supervisor License can be found at ww•w.mass.,;odL,
2. When substantial work is planned,provide the information below:
Total tloor area(sy. ft.) --___ _(including garage, finished basemenVattics, decks or porch)
tiros; living:urea Oil R.l -- f rabitable room count _
Number of tirapI'lee _,--_,----- Number of bedrooms
Number ofbathruoms Number of halt-baths
I'cpu of he.uing syslem - —"- Number of decks"pure tcs -- ."—__--
I'}pe of coolie" ;y;tcm .-_-- -- Fuclosed —__ " )Pell
-------- --
� i. "I' v,il I'nq.,a iyu.ira Pi,nt.i�a" m.tv he ;ub;ttnn: l L+r 'I' ,r.il I'nijcd l'o;t
CITY OF sm-Em
PUBLIC PROPERTY
DEPARTMENT
a„u..aan o.urura.
w►oe r b 7u•wrrssr!Masi•3Kay.V�,►ow urn of f'0
rtL Ci71s9aN .r.uL f78.110.964
HOMEOWNER L.ICENSS EXE.UMO►V
P1eaw !afar
Date -41-u !,013
lob 1.49291011 Si- S" . S,l._.., AA,9- ti 14i O
Home Owner Addmas mow,e
Home Ow asr Telepbow -- "Tr-9x,- >7 L? q
Pr essor Msillag Address z,H.,e;
The Curtest exaapdoa of"FiomeowWe was extended to inchtde owner occupied
dwellings of WO Units err few and to allow nick homeowners to engage an individual for
him who does not possess a licasso provided that the owner acts as mpntvisw.
DEFRr NON Of HOMEOWNER
Person(s) who owns a parcel of Lod on which WAS resides or Intends to redder an
which than i6 or Is intended to ber a oaf or two 11mily dwelling, attached or detached
strttcttues accessory to Mich use and/or farm structures. A pawn who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeowners"1W submit to the Building 001cial,on a form acceptable to the Building
OQlcial, that halahs be responsible for all.such work performed under the Building
Permit
The undersigned "homeowner"usumes responsibility for compliance with the State
Building Code and other applicable by4awt arsd reg ladons.
The undersigned "homeownea"cerdRea that hNshe understands the City of Salem
iuilding Department minimum inspection procedures and requirements and that he/she
-vill comply with said procedures and requirements,
HOMEOW`IERSSIGVAiLRE
kPPROVAL OF BUILDNG LVSPECTOR
Sea other side far stile code
L
CtrY OF S'[ EN[ �
.``'t;'�� j(r>� QL'tLnLvcDEp.t4TtitgvT
yf.4 l?O C'/A3J4 VGTO,VSTtEST, jwROaR
� TEL (973) 715-9595
KiMMUEY DRISCOLL FVC(973) 7.14-934,1
,b L�YOR TF(O1G19 ST.PtaAttB
DIaECroa OF pt:auc pR0FEBTY/9(:uzLYG COSL\(tSsION ER
Construction Debris Disposo! Aft7davit
(required for all demdlition and renuvation work)
in accardanco with tha sixth cditiurt of the State Building Cada, 73o C,hiR section l l l.3
Debris, uid the pravisiunst of,b(GL a 40, S 34;
Building Permit� is issued with the condition that the debris resulting from
this wur!c shall be dispuscd of in a pruperly licensed waste disposal rthatauili th as dutfncd resulting
rtig from
o
1'11a debris will be transportcd by:
NafL, S�Pe .
(Hama ut'haular)
The debris will be disposed ot'in
(namc nt I�cdit�)
I
AA.+
(idh esv ur ei,c6,x)
iSnamra.ofpern i
PPliartit