14 GARDNER ST - BUILDING INSPECTION (2) � C)
REM Fl)
(� The Commonwealth ofbiassachusetts MPECTIONAI SERVICE F
Board of Building Regulations and Standards
M Massachusetts State Building Code, 780 CMR 1on APR 2
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling
This Section For OIII se Only
Building Permit Number: Da g Applied,
Building Official(Print Name). Signature, - Date
SECTION 1:SITE INFORNIATION
1.1 Property AJ ress: 1.2 Assessors Nlap&Parcel Numbers
14 (s\�1 r �.r -�
I.la Is this an accepted street?yes no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
gngct Proposed Use Lot Area(sq It) Frontage(R)
g Setbacks(R)
Front Yard Side Yards Rear Yard
Provided Required Provided Required Provided
1.6 Water Supply:(Ivl.G.L c.40,§5d) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Munici al O On site disposal system ❑
Public❑ Private❑ Check if es❑ P
SECTION 2: PROPERTY OWNERSHIP,
2.1 Owner'or Record,
rm"Jvp C,
fine`(Print) l L City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check ll that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specity:
AS
BrieFDescriptionofProposedWork': l �� YlcClc rb5I�11 Ki eh
SECTION a:ESTIMATED CONSTRUCTION COSTS
Item Labor
Costs: Official Use Only
Labor and Materials)
I. Building $ `�p G 4- 1.
1. Budading Permit Fee:$ Indicate how fee is determined:
❑Standard City/Tgwn Application Fee
2. Electrical S V O ❑Total Project Costa(Item 6)x multiplier x
3. Plumbing S ( C, o< P Qther Fees: S
a. Mechanical (HVAC) S List:
5. Mechanical (Fire S Total All Fees:S--
Suppression)
Check No._Check Amount: Cash Amount:
6.Total Project Cost: S J 10 C'o ❑Paid in Full ❑Outstanding Balance Due:
SeXJr y jz2,
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
o License Number Expiration Date-
r :
Name ofCSL Holder
List CSL'fype(see below)
No. ;aid Street
Type'. _ Description .
- U Unrestricted(Buildings tip-to35,000 cu. IlJ
R Restricted l&2 Family Dwelling
�Cityfrown,State,"LIP M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
IIIC Comp:my Name or fIIC Registrant Name
No.and Street Email address
City/Town,State ZIP Tel e hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I..c.ISL§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 Is✓;uance of the building permit.
Signed Affidavit Attached? Yes ..........0 No...........❑
SECTION 7a:.OWNER AUTHORIZATION TO BE.COMPLETED WHEN,'
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
^^ff ( Q
1,as Owner of the subject property,hereby authorize
t9 act on my behalf,inl all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) a e
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.
0 1 11� a �,-) ) 5
Print Owner's or Authorized Agent's Name(Electronic Signature) Dale
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 not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.;o Information on the Construction Supervisor License can be.found at www.nmss.!ov%'dns .
2. When substantial work is planned,provide the information below:
'total tloor area(sq. ft.) 'r (including garage, finished basement/attics,decks or porch)
Gross living area(sq. It.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
type of heating system Number of decks/porches
Type of cooling system Enclosed Open
1. "Ifotal Project Square Foolage"may be substiurted tor-Total Project Cost"
` r
QTYOFSALEM MASSACHUSETTS
BUILDING DEPARTMENT
�) 120 WASHINGTON STREET,31D FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KINEERLEY DRISCOLL
MAYOR TrIOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CON&IISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRIN
Date G
Job Location /"I G \f\e -
Home Owner Address `! y
Present Mailing Address 5111`17� s� ,4NAyk - 60T o
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 SIGNATUR
APPROVAL OF BUILDING INSPECTOR `/
• T
QTY OF SALEM, MASSAa USE TTS
BuiLDING DEPARTMENT
120 WAsnNGTONSTREET,3RDROOR
TEL.(978)745-9595
RIIvIBERLEYDRISQOLL FAX(978)740.9846
MAYOR THOMAS ST.PIERRE
DIRECTOR OF PUBLICPROPERTY/BUM.DING COWUSSIONER
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 c40, 5 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:
(name of hauler)
The debris will be disposed of in:
(name of facility)
�tr,�,�sco� Rh• �I��.ew l
(address of facility)
ignature of applicant
�H/ ice
Date