7 GRAFTON ST - BUILDING INSPECTION (4) y� The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
ELM
Massachusetts State Building Code, 730 CNIR St\Lfar r
2Ul l
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar
One-or Two-Family Divelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Buil g Official(Print Nama) Lou V Signature - Date
SECTION I:SITE INFORMATION
.1 Property Address: 1.2 Assessors Map& Parcel Numbers
7 (�p-aikon ;t
1.la Is this an accepted street?yesX_ 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 Wat Supply: (M.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Pub ' Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal systemj
Check if es❑
SECTION 2; PR OPERTIG'OWNERSHIPL
2. Ownert of Record: 61�-70
1�0,n�2( �uMIcG r�
Name rint) ity,Sta e,ZIP
R� $Dg1-R3q bio"be� 139342auoM
o. and Street Telephone Email Addr
SECTION 3: DESCRIPTION OF PROPOSED WORKt'(check all that apply)
New Construction Cl Existing Building❑ Ow -Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Additio
Demolition ❑ Accessory Bldg. ❑ ZurnbercifUnits Other ❑ Specify:
Brief Description of Proposed Work': 1 tti o 9
o1r�r4- Fl?rkr;ccl 'la be rlore Fi liQlStip F12c.(c�u —sEpuu';r' (yr,v.;� '
SECTION 4: ESTINL4TED CONSTRUCTION COSTS
Estimated Costs:
[rein Estimated Use Only-,
Labor and ivlaterials
1. Building S ozjp vt� I. Building Permit Fee.S Indicate how fee is determined:
2. ElectricalS G.Standard.City/fown Application Fee
❑Total Project Cost(Item 6)x multiplier x
f 3. Plumbin; S 2. Other Fees: .S
I. ,Mechanical (IIVAQ S List: —
i
). ,Medrutical (Piro
y S 1'utal All Fees: .S iiF ttei5 run) __ -
� Check No. Check Auwunt•. C a;h .\inuunt'
n fnhtl Project (*osC S �� --- - --
❑ I'ii l in Pull ElOuhtuwhn II dance Uri
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number — -- Expiraton Date
Nume ot'CSL [folder List CSL Type(see below)
Type Description
No. and Street
U Unrestricted Duildinlds UP to 35,000 cu. ft.
R Restricted IA2 Family Dwelling
City/rown,State,ZIP �I blasonr
RC Roatin Covering
WS Window and Siding
SF Solid Fuel [turning Appliances
I Insulation
Telt hone Email❑ddrtss D Demolition
5.2 Registered Home Improvement Contractor(HIC)
►IIC Registration Number Expiration Date
f IIC Company Name or MC Registrant Name
No. and Street Email address
City/Tow ,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 wilt 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 matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7h: OWNEW OR AUTHORIZED AGENT DECLARATION
By ntering my name below, I hereby attest under the pains and penalties of perjury that all of the ' ormation
c tallied in this application is uc and accurate to the best of my knowledge and understands l
riot Owner's or Autlwnted: ;tn 3 •(Elecronie Signanut) Date
NOTES:
I. :kn Owner who obtains a bit mg permit to do hisihcr own work,or an owner who hires an unregistered contractor
(nut registered in the Home lmprovement Contractor(HIC) Program), will nat have access to the arbitration
program or guaranty fund under M.G.L. C. I42A.Other important information on the HIC Program can be found at
teww m:u+.euv oca Intormation on the Construction Supervisor License can be Found at to wtv.mass.•tu -Jlr;
3 When substantial work is pLmntd,provide the information below:
l'oml floor area(s,l. It.) — _(ineluding garage, tinished hosemenVattics, decks or porch)
living area(sy. 11.) __ ►Ltbitable room count --
Nuutber of lireplaxs.. _ —_--—_— Number-of bedrooms
Numhcroth.ithrooms _ Ntunhcrofhalf'baths .._------ _
rcpeofheatin ;yucca _..-. _ Numberofdockslporche:
I •,I"!ofunlin- :v;lmit _ _.-.-. lindosed tlpcn
� . ' F.rt.d Pay:e[ �yu.ua F�„�t.i�,c' in.ry he alb:hnu:�l L,r'i,��.il 17njrcl l or;t
CITY OF S.U.Em
PUBLIC PROPERTY
DEPARTMENT
U»1/fY rurvr�
VwYq 1 b W%o w9'al Imam a Splay VAwAa1a sgm et 9V,
ML t-WAS.9Nt •V%x t'3.74&994
HOMEOWNER LICENSE EXE.ti MOV
Pled"Ptriat
Data _
Job Location Sat," l/
Home OwnerAddreaa —I A- a4,)an f�i , Scal2W
Hom oorsov7eleghoae G-R • Ram uR:z�
Present Mailing Addrowt 4Ar e- t-
he current exempdon of"Homeowners"was extended to include owner-occupied
dwellings of two Units or tern and to allow such homeowners to eagage ao irsdividual for
hire who.does not poeaeas a lieeaso provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which horshe reside@ or Intends to redder on
which there i; or is intended to ben a on or two family dwelling athched or detached
stnaoturee accessory to such use and/or farm structures. A person who construct@ more
than one home in a two year period shall not be considered a homeowner. Such
-homeowner"shall submit to the Building Oillcis%an a form acceptable to the Building
Ofl'lcia4 that helshe be responsible far all such work performed under the Building
Permit
The undersigned "homeowner'assumes responsibility for compliance with the State
Building Code and other applicable bylaws and reguladons.
The undersigned "homeowner'certifies that hdshe understands the City of Salem
Building Department minimum inspection procedures and requirements and chat 4/she
Mill comply with said procedures and requir
H0MEOWNERS SIGNATLW
APPROVAL OF BUILDING GVSPECTOR
Sce other side for state code
I
' CITY OF S:IL.Em, itiL1SS:ICHL'SETTS
0I;IL"NGDEP.1AT1MNT
a 1.0 C(/%SHLYGTON STREET V FLO
n ,H . OR
TEL (978) 745-9595
Fkx(978) 7-1d-934S
:<l1tBHftI.EY D2ISCOLL
,�. %YO1t "�'O-NWST.PIERAS
DmECTOR OF PLBLIC PROF EATY/131:MDLYG COSQIISSIONEA
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sirdl edition orthe State Building Code, 780 ChfR section 111.5
Debris, and the provisions of tb1GL c 40, S 54;
Building Permit M is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal racility as defined by��IGL c
t 1 I, S 150A.
The debris will be transported by: /
—�1 irk n
Inantn w ,awar)
The debris will be disposed of in :
(name Ot•Facility)
(addros.c Of tactility)
si3na r O permit applicant -
s-4
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