3 A FRIEND ST - BUILDING INSPECTION -:... - `.----- ---- - i hr
t liu.ud of liulldut).: Iti ul unms Ind St Ind ids IIt
' \II `Il III \III
\lasso husrns Slate 1uilding Code. "SI) l MR. 1 Cdtl,yr
� . Building I'rnnil ReuM.nr Ur I)enll•li,h a .II.,n
(hII•- err /llr t- 1 -
f- _ -Ihu Sernun For (ifhuull ,e lh(iv
Ifu Ild Itrip I'ar nut .N ether. - - _ .-__.�h,llr \ppheJ
i g
I I }Cnnuni,.ikmu hnL. IiI I ISwldmes U.u• .--- .
SE( I'ION I: SI I E INH)R\lA7ION
1.1 !'roper ddrtrss: �- - -- -- I.-' \ssessors Map & Partt.I Nuuthrrs
\L, Nn nlher
i.lu is lhu .m accep(ed ,lr«t )ems -...._ ilu___—_ p y
ji.', Zoning Information: 1.1 Prupeiiy Ginunsiuns:
1.5 Building Setbacks (ft)
Front Yard Side Yards Rcar Y:uJ
Reyuu.•d Pros WcJ Reymed Provided Rcyiuied Plu.iu'd l
i 1.6 Water Supply: 1m (j I_r. 10 §;4_,t 1.? Flced Zone f o!'ormatiun: 1.8 Sewugr Disposal tiysta•m:
Zone' _- Outside Flood Zone"
Public ❑ Pnvare❑ I Check I, ves❑ .\lunge:p::1 ❑ On ,ne dulxr.al ss,IcW ❑
SECTION l: PROPE.RI'V GWNERS111P _
1 s Q S L�
A ess utt Sel'.Ice �I
1
1 SIgn:It Ire clrphunr
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check UII that apply) _ J
'--
I New Construction ❑ 1 E<eaing Bolding Ci Owner-Occupied ❑ Repairs(s) ❑ \Jd:w,n r'l
:111eraunm sr ❑ -.
1?c•IT101 III n ❑ Aeecev,ry BldK ❑ Number of Units 1Other.X SSPCLIly -"-e-
�- - — �e - � - - __ --�-tea•-- _..�:✓L� � I
Brier r pu::r r P o ad W Y':__ r Y_
31
_--- �-_ - - Sr:CTlW. is ESTIMATED CONSTRUCTION COSTS _
f]oilnl:i ifU j Item — ),t Official Use Only
I Lah�a .Ind \t;I trn;l
0.h lsl
I Billng ; _-.-_._. i I. Budding Perrot Fee: 'S - Indicate hI,u tee Is delenuuled:
------ - ❑ Standard Cny/I")wn Apphcan.)n Fee
_. F.Iretncal '!
❑ Total Prefect Ctnt (item 01 \ multiplier _ _ r
7 Plwnhln '` �, Other Fees: i
_.
r t'll Aii Fees \
~ ( heck No ( he-is AItnnI41 (*.i,h \nn.unt
n :utal Project Cost � 1' _///.'•••���❑ P.ud In Full — '�G�()u_,h/�t d//nJl I_ 13.11_�n.e Uuc_. ._. _. _.
SECTION 5: CONSTRUCrlON : .R% I( ES
5.1 I.icensedCunslructionSupervisur (C'SL) — --- —_— --� ---,i. .�
lllnhir I.\pll.11n ill Il.11i '
NJ;nc,n ( SL II,,]Jcr
i LI,I SL I's pe nii hiLn,l
( l n1i HIh ICJ pup lit (-(1
--_--_— -- R Risu l.IiJ I,@' fJ1n1h UoilLu.
f:li ph„no (14—�Ri�iJc nl till \\teat„ .ir.J ):Jar_
J;total tiuhJlail lS�,u 1in`1LL,L:u1,:
D R:aJi I l i.J
5.2 Registered Home Improvement Contractor I IIIC) —
III(' ('nnq+.uo Name or IIIC RCgI,IrJlll NJIIIC
-- _— Rcgooauun Numhci
F.yn Jwm U:aC
1 s,gnatu1e — telephone
SECTION 6: WORKERS' CONIPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. 9 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to pros 1Je
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
1. as Owner of the subject property hereby
authorize, to act on my behalf. In all nl.uters
relative to w-nk authorized by this building permit application.
S I¢nature' Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, as Owner or Authorized Agent herehy declare
that the iaacements and Information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Name --
1
Slenature of Owner or Authorized:\gent Date _---
151 med under due arcs and enables of e(u )
NOTES:
I. An Owner who oblams a building permit to do his/her own work.ur an ow-ncr who hires an unrngl,ICICJ l,n1111. his 1
(nut registered In the Home Improvement Contractor 11110 Program), will nirt have accc,, to me athriato-o j
program or guaranty fund under M.G.L. c. 112A. Other Important iph,imation tin (he IfIC Program .Ind
Construction Supervisor Licensing I(SL)c.In he found 1n 780('JIR Regulations I MR6 .u1d 1 II) R5. ic,pecoscls
When substantial work i ,planned, pnolde the'intormation below:
T„taI tlours area ISq. Ft.) - (Including garage, finished hi,emen1/altic,. deiks ,,I p„rih,
Gross lone area ISy. Ft.) Habnahle room count
Number of riteplaces _— Number tit hCJru,nns
Nunlher or tmthnaon, NUMhel' „t h.,l Uhalh+
fspe ,Il hearing v,(cm _ Number ,d dc,k,/ pt 1.hc,
1�11.LocJ _._— - . ul;i❑ - _._ ____—
? .:h,aal Project tiyuere Footage may he ,uh,ututed t,,r "(„(,tl Pr,gcct ( ,,,t
r
1
CITY OF smx-m
PUBLIC PROPERTY
DEPARTMENT
,%"VM 130 WADUPWT M STREXT 9 WAK MASAO*--XM 01970
T m-TWUS-959S* FAX 978-7449W
HOMEOWNER LICENSE EXE.MMON
Please Print
Date I
Job Location 34-
, "S>
Horne Owner Address
LljaC
Horne Owner Telephone
Present Mailing Address
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.
It
DEFINITION OF HOMEOWNER
Persons) 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
thadone 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 reoui=cnts and that he/she
will comply with said procedures and nmuirements.
HOMEOWNERS SIGNATURE p
APPROVAL OF BUILDING INSPECTO Z
See other side for state code
CITY OF SALEM
A if PUBLIC PROPRERTY
;J ` DEPARTMENT
IN n<i:rr • SA rat. NI\,;\I 1. <i i .
l l'I 978-N5.9;95 • 1 \S: 978�174 '1 4t,
Construction Debris Disposal Affidavit
(re4.11.1iied for all demolition and renovation work)
In accordance %�itlt the sixth edition of the State Building Code, 780 Ch9R section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit it . -. is issued with the condition that the debris resulting front
this work shall be disposed of in it properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
�CLA-
_ - (name of hauler)
t
I'he debris will be disposed of in
(name of facility)
(at ,�iity)
C71kl-d. A)
signature of permit applicant
date ---._--