41 FRANKLIN ST - BUILDING INSPECTION (2) r 5
the Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR Revised,thir 201
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling o
This Section For Official Use Only cM
Building Permit Number: Date Applied: ="m
r�o
Building Oliicial(Print Name). _ Signature Dog
1 SECTION 1:SITE INFORNIATION` cw '
LI�f'r erq dr Z s: t 1.2 Assessors Map&Parcel Numbers
1.1 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 R) Frontage(11)
1.5 Building Setbacks(1't)
Front Yard Side Yards Rear Yard
Reyuin:J Provided Required Provided Required Provided
1.6\Pater Supply:(M.G.L e.40,§5d) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public[3 Private❑ Check if yesO
SECTION2: PROPERTY OWNERSHIV
2.1 Omer Lrpecor : ✓1 =th2t'flpply)
(Print) l p>S CityState ZIPNo.and Stmet Telephones
SECTION 3: DESCRIPTION OF PROPOSED\PORK=(
New Construction❑ Existing Building❑ 1 Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition 15
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work2:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S P Qther Fees: S
d.Nlechanical (HVAC) S - List:
5.Mechanical (Fire S Total All Fees:S
Suppression)
Check No._Check Amount: Cash Amount.
6. Total Project Cost: .S 'L O O ❑Paid in Full ❑Outstanding Balance Due:
!Y)A t (_� TZD 20 S NoeT�-1 s7 s
rY,atU lo 'Zp
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Cmtstruction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder List CSL Type(see below)
Type - Description
Nu. ;md Street
U Unrestricted DuilJin u �to 35,000 cu. Il.
R Restricted 1&2 Flunil Dvvellin
Citylfuwn,State,"LIP M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No. and Street Email address
City/Town,State ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.0 C.ISZ.$ 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 lac OWNER AUTHORIZATION TO BE COMPLETED WHEN' -
OWNER'SAGENTORCON`fftj TORAPPLIES FOR BUILDINGPERMIT
1,as Owner of the subject property,hereby authorize
t9 net on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW ORAUTHORIZED AGENT DECLARATION
By entering my name below, nttest under the pains and penalties of perjury that all of the information
stained in this application is true an accurate to 1te best of my knowledge and understanding.
• Electronic Signature) Date
Print Owner's or Authorize)Agent time( gt )
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 Home Improvement Contractor(HIC) Program);will wgr have access to the arbitration
program or guaranty fund under INI.G.L.c. I42A.Other important information on the HIC Program can be found at
%vww mass cov,'oca Information on the Construction Supervisor License can be found at vv�v:lJns _
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) '+ ,(including garage,finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room coma
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type ofcoolingsystem Enclosed Open
3. "Potai Project Square Footage'may be substituted fur-Fatal Project Cost"
077Y OF SALEA MASSAGASE M
BurmnJGDEPAiamE '
' 120 WAstIIPi=N MEET,31DFLooR
7kL(978)745.9595
RIMBERLEYDRISODLL FAX(978)740•9846
MAYOR TrEUras STAEM
DntEcroR op PUBLrcrxorERTY/BuaDm oammomR
Construction Debris Disposa/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 c40, S 54, Building Permit 4 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: Q
VV 111 > ;✓�� (ejX a nW. ,E,�- - JAG
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signatur of applicant
l v i5�
Dat
aQTY OF SALEM, MASSAC HUSE TTS
BUILDING DEPARTMENT
120WASFHNGTONSTREET,3" FLOOR
TEL. (978)745-9595
F
KIMBERLEYDRISCOLI, FAX(978)740-9846
MAYOR TxOMAS STTIERRE
DIRECTOR OF PUBLICPROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date /r 6116 /i5_ / ✓✓��� l^ 1 (��LJ Q ,y/
Job Location //�J —f�l�c2t /f . l /'U (S ✓ . y� ln/_n //r� /6/ 776
Home Owner Address t7/!} ��ill��/r/{`v/ �e MA6/f•7 0
Present Mailing Address 7C (�, ( , 11 �� �p/yJ /y7 A C7 !97 G
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 INSPECT