5 FLINT ST - BUILDING INSPECTION (2) c 30q V,
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FCEiVEO
The Commonwealth of MassachuS&OPECTIONAL SEF\ ICLCITYOF
Board of Building Regulations and Standards r�SALEM
` q J Massachusetts State Building Code, 780 CI18 OCT 3 U P Agv5 mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
TJ) This Section For Official Use Oni
I
Building Permit Number.- Date plied:
11 �
Building 011icial(Print Name). Signature•. Date
I SECTION 1i SITE INFORMATION
1.1 Property Address: S9tz"4 AV:V 1.2 Assessors blop&Parcel Numbers
, Cc/u r 0/910-5W
1.to Is this an accepted street9 es_ no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
"Coning District Propose)Use - Lot Arca(sq R) Frontage(R) - -
1.5 Building Setbacks(R)
Front Yard .. Side Yards Rear Yard f
Required Provided Required Provided. . Required' Provided
1.6 Water Supply:(M.G.L c.Jo,§5J) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Pubitc O Private O Cheek if esO
SECTION2: PROPERTYOWNERSHiP!
2.t wnertofRf�ord:
/RCE S/W,..vl, MA o
�tS6'J CF_
"e(Print) City,State,ZIP /rSF
,rFLIA)T-Smcc- '1 87�/y-?� 36CowrrxasM/GBtatiohS." Pik
No.and Street - Telephone Email Address
CTION 3: DESCRIPTION OF PROPOSED WORK°(check all that apply)
New Construction o Existing Building Owner-Occupied Repairs(s) Alteration(s) 17 Addition ❑
Demolition O Accessory Bldg.❑ NumberofUnits_ Other 13 Specify:
Brief Description of Proposed Work': C 3'
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Itan - Estimated Costs: - Official Use Only
Labor and Materials -I• - - -
1. Building $ 6660. Building Permit Fee:$ Indicate how fee is determined:
O Standard City/Town Application Fee
2.Electrical ❑Total Project Cost'(item 6)x multiplier x
3. Plumbing S 0, 0 211 Qther Fees: S
d.&Icchanical (FIVAC) $ List:
5.MecEk
$ Total All Fees:S -
Su X Check No. Check Amount; Cash Amount:
G. Tota $ 8D00. �` 0paid in Full 13 Outstanding Balance Due:
t
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL[folder List CSL Type(see below)
No.:utJ Street Type. - `_ Description
U Unrestricted(Buildings tip-to 35,000 cu. It.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Rooting Covering
WS WindowandSidin
SF Solid Fuel Burning Appliances
1 I Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
I TIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town. State ZIP Telephone
SECTION 6eWORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G.L:c.152.1 25C(6)y,
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 ..........O No...........O
SECTION7a- ERAUTHORIZAT10N:TOBE.COMPLETED WHEN.
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT'
1,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Nante(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
niis true
uee and accurate to the best of my knowledge and understanding.
PrintOwner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do Iris/her own work,or an owner who hires an unregistered contractor
_knot registered in the Home Improvement Contractor(HIC)Program);will no have access to the arbitration
program or guaranty fund under M.G.L.c. 1d2A.Other importnat tnfotmaTion on the HICYrogram can be toimd t---"—" "--"
www mass eov:'oca Information on the Construction Supervisor License can be round at w�v;dns .
2. When substantial work is planned,provide the information below:
'total floor area(sq. ft.) N .(including garage, finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Tape of heating system Number of decks/porches
Type of cooling system Enclosed Open
.1. "Total Project Square Footage"may be substituted lur"'fot:d i'roject Cost"
OTYOF SALEA MASSAalUSETIS
BEaDmDEPARneNr
120 WASHINGzNS7REET,3IDRADox
7kL(978)745-9595.
KIMBERLEYDRISOt7LL FAX(978)740.9846
MAYOR THWAS STJUM
DIREcrcaorpmijcpxcn Tr/BumDmcommmomR
Construction Debris Disposal Affidavit
(required for all demolition and,renovation work)
in accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL 00, S 54; Building Permit# is issued 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 debris will be transported by:
h?OAACf44-FTh✓CS (' 13i1�GlYdG-Ca���7�►t)
(name of hauler)
The debris will be disposed of in:
MgW-b PtSPMA-L C012P
(name of facility)
qr aN Ny S a r- ��,o�2,U. 7owf; Nth D16�3 3
(address of facility)
Signature of applicant
_ 83 . N6uFA41?x' t- 201�
Date
° QTY OF SALEM, MASSACHUSE TTS
BUILDING DEPARTMENT
120 WASERNGTONSTREET,3" FLOOR
TEL. (978)745-9595
KIMBERLEY DRISCOLL FAX(978)740-9846
MAYOR TY-IOMAS STTIERRE
DIRECTOR OFPUBLICPROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date 0-2, .beer opt . go
Job Location -Ar S• ;L/#UI— STi2a of�SA�r*�!,074 D l9W —3///
Home Owner Address 057
FelWT S'%XCX Ste ?,, M/) D/F!A)—'X//Z
Present Mailing Address J /�//�/�STQ/� �gL�y'Kq hfif 0/,?7v-��/�
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