0037 FORT AVENUE - BPA-12-570 -- The Commonwealth of Massachuscits
l rl Gourd of(3uilding Regulations and Standards CI'I'), OF
Massachusetts State Building Code. 7S0 CNIR SALE,\I
Ir,•tised.lfar nil
Building Permit Application To Construct, Repair, Renovate Or D olish a
(fir-or Two-FunnIV Dwelling
This Section For 01'ricial Use Onl
Building Permit Number: Date App ed;
BuilJing Oltieial(Print N;unc) Signature Ualc
SECTION I:SITE INFORMATION
L I Property Address: 1.2 Assessors Map& Pareel4umbers
I.la Is this an accepted street?yes no Map Number Purcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed(!xe Lot Area(sq 11) Frontage(Il)
1.3 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1.c.40,§Sa) 1.7 Flood Zone Informatlon: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Munici al ❑ On site dis
Check iF es❑ p posul system ❑
SECTION2: PROPERTYOWNERSHIPt
2.yOwnert of Record
� � i2 o � 2r kV
Name(Print) C ty.Jlate.Z.IP i
Nu.:m Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Itcm Estimated Costs:
(Labor and ..Materials) MOM Use Only
I. Building S O I. Building Permit Fee: f Indicate how fee is determined:
2.
Electrical S (,Z 99 Q ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier
j 7. Plumbing S ?, Other Foes: S .../_xl._
a. \lechunical ill\.\('1 5 List:- ----_' —
5. \tcchamcM Wire .—__----
Cu t trosion I S Total .\Il Fces: S
('heck No. Check AMOL1m: Cash Amount:
b. Total Project Cost: S ---- - ----- ..
Q ❑Paid in Full 13 Outslanding Bakutce Due:
SECTION 5: ('ONS1'RUC'rION SERVICES
5.1 Construction Supervisor License(C'SL)
License Number -- --- Fgriratiou Date
\':unc ol'CSI. I IulJer
I ist('St. I)Pe)see
Nu PC Description
.old 5trcel ----------------- ---------- by
U I larestricicd(Buildings iii to 15,000 al. 11.)
Restricted 1&2 Family Dwellin
Cilyil'o+sn,Slate.LlP M1I Alusun
RC Rwrlin Covcrin
and Siding
SF .Solid Fuel Duming Appliances
I hlsulation
I'dcliholic Fn1ail address ) Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Registration Number Fspiruliun Dale
I IIC Company Name or I IIC Registrant Name
No.and Street Email address
City/Town.State,ZIP rcle hone
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 AMdavit Attached? Yes ..........❑ No...........O
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
h as Owner of the subject property,hereby authorize
to act on my behalf,in all platters relative to work authorized by this building permit application.
Ko �ZR ( k c/
Pant Owner's Name(Electronic Signature) Date
SECTION 7b:OWNERI 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,
Print O+,ner's or Authoriied,\gcnt's Name(FIcclrunic Signature) Date
NOTES:
I. 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 Hume Improvement Contractor(HIC) Program),will nu have access to the arbitration
program or guaranty fund under.1.G.L.c. 1 a_'.a.Other important information on the HIC Program can be found at
,+++„ m.l,. + k i Information on the Cunstruction Supervisor License can be found at++„+, w.ts+ �j_n -It,.
2, When substantial,wrk is planned,pruside the information below;
Total fluor area tsq. ft.) _ I including garage, finished basement attics,decks or porch)
Gross living area I sq. it,I - Habitable room count
\umber of fireplaces__ Numherofbccirooms
\umber ol'bathrooms Number of half'halhs
f)lie of heating >y stem Number ot'decks porches
i
I1pc+dcoollllgssstem I?ncloxd Open
�. "fa6d Project Square Footage"nlay be substituted for"total Project Cost'
CITY OF S.UY.Ni
PUBLIC PROPERTY
DEPARTN, LENT
u.o�aur n�=ems
VwrM 130w.wAGrOM*MW•sera VAoAoRfsm011'0
HOMEOWNER LICLNSB EXE.1 "10M
Plwu trine
Dale /Z- /z — I/
Job[.ocadon _ 77 F D 6Z T A U C^ S<9(' C M ,NIA W410
Home Owner Address 7 7 Fd 2'T V F 5-A e-Fyn l:7Iq 0(4-YK0
Home Owoer Telephood
Present Mailing Address
The current acempdon of"Homeowners"was extended to include owner-occupied
dwellings of two Unite or►ear and to allow such homeowners to engage an individual for
hire who.does not possess a liccus%provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Persons)who owns a parcel of land on which ha/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 OQlcial,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 regulation.
The undersigned "homeowner'certifies that he/she undentands the City of Salem
Building Department minimum inspection procedures and requirements and that helshe
Mill comply with said procedures and requirements.
HOMEOWNERS SIGNATURE '� (("r- /-4 v C/
APPROVAL OF BUILDING INSPECTOR
See other side far state code
r
CITY OF S,V-EM, Akss.kaiusErrs
9LLWLNG OEP.%A-n LL
\T
120 W ksmLNGTON STAIEBT, jw FtOOR
TtL, (978) 745-9595
KIMBERL8Y DUXOLL F.Vt(978) 740`9946
MAYOR NoxU ST.PMUZ
011=T0E OP PLBUC PROPE171F/SVILDOJG CoNailSSIOV EA
Construction Debris Disposal Affidavit
(required for all demolition and rcnovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section I I I.5
Debris, and the provisions of MOL c 40, S 54;
Building Permit H is issued with the condition that the dcbris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defincd by NIGL c
111, S 150A.
The debris will be transportcd by:
N0 'fh Shope !Yn
(name of hauler)
The debris will be disposed of in
y (name of facility)
G1/ - 1, K �' I (/ 1 7 V
(iddresr orrjeillty) F
r' ✓ /�
❑ynaturo of permit ipplicant