2 DEARBORN ST - BUILDING PERMIT APP I he (',unnvnr.a.Jlth ul %fa`S.iLlILISCII`,
l
liuurd ,d liuddinL RCCuIallun, mid StanJJrJ, \II NI( II' \III 1
\1❑ssarhusens State Huilding C, JC. 'S(I( '\IR. ' cdul,'n 11
l
IitIlIdln^_ PeI'IIIIt ppIli.1tloil TO ('01INII"tli1. RCpJII RelHta,ItC (h D l,),'ll,l) .1 !< • .! lnri„n
~— I"hls Strnun Fur Offie is) t\r Unly -----_--- -
���111 Bu:IJinss Perini' .Numhrr
13wIJ,11p ('tit nnu..umry Impealor of ILulJuies [).lie
SEC 1'I11N I: SI"1'E INFORMA FION
1.1 Property \ddress: - -- j 1.2 \sse sors Nlap r Parcel ssumbers -- - -
I.III I. this ____ ___ ''I:n ^.anther 1',u.rl \uu:h.:this .m �,vCt �
.:caipl:•J �• ' c, nu ! :
Proper:y bintrmiuns: j
I C.nnmg Iiulnat ,e I La A:aa"y lit -
j LS Building Setbacks (f
Ftnt Yard — Side Ycrds _ _ar_Y.0 J {
Rulu 1 Pn,a ided Required Pntv:da-) R.yuued P, _J
1 1%„te.. SUPPly: !.\1 O L a 10. §51) 1.7 Flood "Lone Information: 1.11 Sewage Disposal S)Stcm j
Puhfic Z
..,/ Zone: Outside Fhx)d Zone
Private ❑ .Ylumapal �/On a Jnpo I a.ic:n ❑
Check rt yrSFa" 1
SECTION 2: PROPERTY OWNERSHIP' _ )
r?.I C?rvaer'of ecord:
2 Ixa rla(,yr)
_I__A :\ddreulbr Srrai cr--
_ Tclr inane
'i!�,nrlwc
SECTION 3: DESCRIPTION OF PROPOSED 1VORKz(cheek all that apply)
— --- ��- —
:.�: Cunstrucuun ❑ Esis(ing Building (ha nee Chaupird I Rrp wsl_ 1 ❑ j Alteruunnl,I WJi �n ❑
D, mulawn ❑ Ages+ory Bldg. ❑ Number of Units Other ❑ Spcaiy —
Dcscnpuun ,tiPr,puse WOr -
SECTION 4: ESrlMATED CONSTRUCTION COSTS —
E,tlmafed Cuss: --
[tern "- -- I
fficial L'se Only
Il.ahur.md �1urrn::lsi O�
I Building \ "y�U(i. e., I. Building Pcnnit Fee, 3_ _ Ir.dlCure hu as fee �, JCi ri111i nCJ
O Standard Ci(,v%I'u:vn .i ppllcuuun Fee
SGOC.t, I Iumhln , 5 �d --i ❑ -rUlal PngeC( Cu,[ (Item G) a in:ahpher ',
Gd _
Electrical ) l G,B
_'. Other Dees: S _
4 Mechanical iH\':\CI _--
! j \lea hamc.J IFire --
I'mal AH Fee,. 1
1u ' nc„n,nl -
_ _ ( heck No _ Cheak _Amuunr l'd.h \nnuinl
it total Project Cost ❑ Paid in Full 0 Out ,fmldim li.J.ln__• U:_c_
SECTION 5: CONSTRuc riON SER% ICES
5.1 Licensed Construction Su per%isor WS 1.)
1 A,.isle ,1 ( St. Hold"
St. I\pe nee hclon%J
iw,.I,iej •t..p io
�RR,,tooed & FavilIN P,,Hmc
R(
14c, J,nll.d .... ...1J
5.2 Registered Ilonic Improvement Contractor (111C)
mccompan� Nimeor HIC Registrjut Nime NtillihC3
Wdrcs,
"Itellatule reiepiione
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. S 2506 1)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failurcto pro,idc
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... 0 No 0
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 behalt. in all in.im-is
relative to ��oi k authorized b) this building permit application.
.Si natuie of 0wner Date
SECTION 7b: OWNEWOR AUTHORIZED AGENT DECLARATION
1. 1 as Owner or Authorized Agent hereby declare
that (he statements and information on the foregoing application are true and accurate. to (he best of my knowledge and
S E
,h., ,h, statements
ntand
behalf
Over
Prull .Na 1) 0
LS
.Signature of Owner orAuthorizedAgent Date
iSi ned under[Ile ain.,and PCnJIJJCS0I EQUO)
-t NOTES:
1. An Owner who obtains a building permit Iodo his/her own work. or an owner who hires an uniegi,teied k1l
k(no( registered in the Home Improvement Contractor (1-110 Program), will tmif have acccs, to me .uhirimi.-ri
program or guaranty fund under M M.G.L. c. 142A. Other important inhumation on the III(" Proizranl .ind
Construction Supervisor Licensing WSI-)can he found in 780 CNIR Regulations I M.R0 and 1 11) 145,
When uhstantial work is planned. pio%ide the mimmation below.
Foijl floors area (Sq. 1:1.1 including gardge. finished ba.,einent/aRILS, decks or ptsi.hy
1 Gross lJvJnL, area I Sq. Ff I Habitable room count
I Number of nieplaces--- Number M thedro,,in,
Numb et or h.uhiooms Numher of ll drhjlll,
heating %,Icm Nurnher ,,f de,k,/ 1)�,i,hc,
\pe ,4 'o"1111g, *,,tcm
3, Halal Project Square Footage- maN he ob,altwed t"I r''I'll Prol"I Cost '
i
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KIldFllaY NwYY
Vwwa t3owwvw+co+s,.rcr•Suea4 Vw�on:sern01970
TU.978-743-9"S * F,ut 978-740-96"
HOMEOWNER LICENSE EXEMPTION
Plow hint
Data
Job Location 7 tWj-hUVh 41` '�—a l r f V LA O)CI-7U
Home Owner Address
Home Owner Telephone G1 •-7 a
Presort Mailing Address 2 1 V bb/V1 �r Wl FAO I L>
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 who,does not possess a license,provided that the owner acts as supervisor.
DEFINMON 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE I a h-&
APPROVAL OF BUILDING INSPECTOR
See other side for state code
•'''" CITY OF SALEM
A( 1 PUBLIC PR(
DEPARTMENT
\i...'C}(g LI-r • 1.\I I \I, \L\ i\i .. I =1'I ..
I I I: v's '4i.);vI; I'\Y: 'i78 'J iShi
Construction Debris Disposal Affidavit
(required li r all demolition and renovation work)
In accordance \%ith the sixth edition of the State Building Code, 780 CNIR section 1 1 1.5
Debris, and the provisions of'v1GL c 40, S 54;
Building Permit it is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(namc ofhauler)
The debris will be disposed of in
(name of facility)
(address of lanlity)
signature of permit applicant
�- )y' og-
Mate