7 GRAFTON ST - BUILDING INSPECTION (3) The Commonwealth of Massachusetts
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, Board of Building Regulations and Standards
ndards
CITY OF
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Massachusetts State Building Cod
e, 730 CN(R
SALEM
Building Permit Application To Construct, Repair, Renovate Or Dm a
Revised Mar 2011
One-or Two-Family Dwelling
This Section.Ftir'Official Use Only.
Building Permit Number Date`ApplieC.
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Buildingr Official(Print Name) ;. Signatu - Date
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SECTION L• SITE INFORMATION,"
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
1.1a 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 ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 ater Supply: (M.G.L c. 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Private ❑ Zone: _ Outside Flood Zone?Check if yes❑ Nlunicipal�On site disposal system ❑
SECTIONZq PROP.ERTYOWNERSHIP?°
2.1 Owner'of Record:
I)rcai[1 OVDD
Name(Print) City,State,ZIP
'l (�rcf_-�yn <---,\ . q_1F.18a9-4831 bl 1�r�13 � in�'caM
No. and Street Telephone ad Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) Alteration(s`)>9� Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other Cl Specify:
Brief Description of Proposed Work':
0''�ur 44 3• coccr6e. tl Wtr4orwA eVx),- - d5' ,.,11 A,--a ' le_k.r- W1
a3aeS� ovrrl�� e1A low. fo�rlal;7 �. T4on o , Sillrrn rna� J)r_ to all weljS
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SECTIO 4: ESTIt IATED CONSTRUCTION COSTS>
Estimated Costs:
Item Official Use Only_,
Labor and Materials
1. Building $ 1. Building Permit Fee $ Indicate how fee is determined:
2. Electrical $ Cl Standard City/Town Application Fee
❑Total Protect Cost''{Item 6)x multiplier. x
3. Plumbing S 2. Other Fees: $
I Mechanical (IIVAC) $ Ltst:
5. Mechanical (Fire $
Su ressimr Total All Fees: ,'S
�� Check No, Check Amount: Cash Amount
6, I'otal Project Cost S asDDs Cl Paid in Full 13 Outstanding Balatico Dna:
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SECTION 5: coNSTRuc,rION SERVICES
5.1 Construction Supervisor License(CSI.)
License Number Expiration Date
Name of CSL !folder
Lis[CSL Type(sae below)
Type Description
No. and Street
U Unrestricted Duildin s up to 35,000 cu. ft.)
_ R Restricted 1&2 Family Dwelling
Ciryfrown, State,ZIP iI Nfasonr
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
l Insulation
'relz hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
FIIC Company Name or RIC Registrant Name
No.and Street Email address
City/Town, State, ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 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 ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property, hereby authorize
to act on my behalf, in all (natters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER' 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 ized A-ent's Name(Electronic Signature) ' ate
NOTES:
I. An Ownerwfio obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(nut registered in the Home hnprovement Contractor(H[C) Program), will not have access to the arbitration
program or guaranty find under\LG.L. c. 142A. Other important information on the IIIC Program can be found at
www mass.<,ovioca Intormation on the Construction Supervisor License can be found at www.nmss._rov!dps
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 nrca(Sq. ft.) 1labitable room count
Number of tureplaecs Number of bedrooms _
Number of bathrooms _ Number of half/baths
hype of heating systun _-_--- Number of decks/porches --
IYPe of cooling syslcn)-- -- Enclosed_- __-_--Open
3. "total Project Squnrc Pootage" finny bo Wb;titutcd r,r"Toml Project Cott" ----
CITY OF SM-E.M
PUBLIC PROPERTY
DEPART1tENT
u vuuav nuruu
Vwroe 13 OWWTONhfYr•Suaa44AMA04Lamset9.0
M rs.7117s" •VAL 1't.7�69W
HOMEOWNER LICLNSS EXE.MMOX
PMaN Frfnt
Data
Job Loeados
Homo Owner Address -? Cwr,f*im SE. - G 41 e t^n
Home Owner Telepbone
Present MaftgAddress 1 GvG }an 91 sa1Cy^
The current exemption of"Homeownere was extended to include ow ow-occupied
dwellings of two Units or toss and to allow such homeowners to angags an individual for
hire who.does not possess a Heenan provided that the owner acts as supwAsor.
DEFINITION OF HOMEOWNER
Person(s) wbs owns a parcel o[tand on which hafshe resides or hdands to reside,on
which these 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
Tho 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
8wlding Department minimwn inspection procedures and requirements and that he/she
will comply with said procedures and rcquir ents.
HOMEOWNERS SIGNATURE I
APPROVAL OF BUILDING LNSPECT
See other side for state code
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CITY OF SiUZ%t, -%L-1SSACHUSETTS
�,.i S L t+. BL'ILD4\G DEP.ART-M&NT
�{ ` 130 WASHLNGTON STREET, 3w FLOOR
\ T EL (978) 745-9595
KI.N(BERT Y DRISCOLL F.kr(978) 740-9846
1AWOR TTto,tAs ST.PMRRB
DIRECTOR OF PLBLIC PROPERTY/8CILDL\'G C01LtlISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section l 11.5
Debris, mid the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of m a properly licensed waste disposal Facility
l It, S 150A. P ryas defined by MGL c
The debris will be transported by:
(name ut'hauler)
The debris will be disposed of in
_-- (name of tacaity) _
(address or tactility)
SljnamrC rmitapplicant
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