20 GARDNER ST - BUILDING INSPECTION file C'omnionwealth of Massachusetts CITY
� Board of Building Regulations and Standards OF SALEM
Massachusetts State Building Code, 780 CMR, 7"edition RevisedJaonevv
�w Building Permit Application fu Construct, Repair, Renovate Or Demolish a /• =t)/)Y
V One-or Tu•o-Fumi.v Duelling
This Section For Official Use Only
Building Permit Number'.. Date Applied: 1
fluildingcommissioltertInspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Add S 1.2 Assessors Map& Parcel Numbers
�� N Ma Number Parcel Number
I.la Is this an accepted street'?yes_ no P
1.3 Zoning Information: I.! Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑
CTION 2: PROPERTY OWNERSHI�P'"/
2.170wner'ofRecord:
6C� S-61r_& 1/S'DN �,o Gin�e Q'L V 7-
Name(Print) Ad cess for Service:
7 VS- Ga 9/
Signature Tfthoncr
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=: '� /7 1
v
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: OMcial Use Only
Item Labor and Materials
1. Building S I. Building Permit Fee: S Indicate how fie is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Costa(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S /A
.{. Mechanical (fIVAC) S
List: < �w IIVJJ
5. Mechanical (Fire S Total All Fees: S
Suppression)
Check No. Check Amount: Cash Amount:_
6.Total Project Cost: S �o4 �� ❑ Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5,1 Licensed Construction Supervisor I(
License Number Fxpiration Date
Name of('St.-I folder -
List CSL 1}pe(see below)
Address ft Description
Il (!nrestricted u to 35,000 Cu. Ft.)
R Restricted 1&2 FamilyDwelling
Signature Al Mason Only
RC Residential RoutingCovering
Fcicphone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
1) 1 Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or I IIC Rcgismml Name Registration Numbcr
Address
Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 2SC(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 .......... O No...........O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
11 , as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 711b:OWNEW OR AUTHORIZED AGENT DECLARATION
1• ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and pynaltics ofPerjury)
NOTES:
I. An Owner who obtains a building permit to Jo his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIE)Program), will trot have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and I IO.RS,respectively.
LNumber
hen substantial work is planned,provide the information below:
oors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
iving area(Sq. Ft.) Ilabilable room count
r of fireplaces Number of bedrooms
of bathrooms Number halt7baths
heating system Number of decks/porches
coolingsystem Enclosed Open
otal Project Square Footage-may he substituted hx"Total Project Cost"
2C,A
CITY OF $m m
PUBLIC PROPERTY
DEFARTNLENT
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HOMEOWNER LICENSE EXEMPTION
Please Pr1et .
Date
Job Loeadion a o'rvg'�
Home Owner Address S
Home Owner Telephone —
Ptesent Mailing Address 2/) �uggelwei-. S O/ 27C1
The current exemption of"Homeowners"was extended to inehtde owner-occupied
dwellings of two Units or less and to allow such homeowners to engage an individual for
hire who.does not possess a lieasse,provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Person(s) who owns a parcel of land on which hdshe resides or intends to reside.on
which there is, or is intended to be6 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 hams in a two year period shad not be considered a homeowner. Such
"homeownee"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"hoinaowner'assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undenigned "homeowner'certifies that hdshe understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING NSPECTOR
See other side for state code
CITY OF S.U.&M, U-1SS.A cHUSETI'S
BULLDLNG DEPARTMIMNT
I1
0 WASHMIGTON STRM, 1'n FLOOR
` TM (978) 74S-9595
FAX(978) 740-9846
KI\tBERLEY DR.ISCOLL
MAYOR THoMus ST.PmaRB
DIRECTOR OF PI:BLIC PROPERTY/Bt:MDLYG COMMISSIONER
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-c 40,-S-54,-- - ------- — -- —
Building Permit Al is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal 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 facilily)
(address of facility) n
signature of permit applicant
date
JcAnvlfJ.�;