1 GRANT RD - BUILDING INSPECTION (2) !' '`
� ,� The Commonweaffli of Masslchusetts
� i �- Board of Building Regulatious and Standards CITY OF
�, ��� , �tassachusetts State Building Code, 730 Cb(R SALEM
Revised A�lar 2011
� Bui(ding Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dtivelling
Chis Section For Officiat Use Only
Building Yermit Numbec , lied:- �
. _ �
/ z�1r��
Building Official(Pnnt Nime) . �. �S�g Date
SECTION 1: SITE [ ORi�IATION
LI roperty Address: 1.2 Assessors Map& Parcel Numbers
f �r, r� �-r 1��1
l.1 a 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 E3uilding Setbacics(ft)
� Fron[Yard Side Yazds Reaz Yard
Required Provided Required Provided Required Provided '
1.6 Water Supply: (M.G.L c. 4Q §54) 1.7 Flood Zone Information: LS Sewage Disposal System:
Public❑ Private ❑ Zone: _ Outside Flood Zone? N[unicipal O On site disposal system ❑
Check if yes0
SECTIOIV2: PROPERTY'OWNERSHIP'.' `
2.1 w er�ofRecord:
. � �y���M �'''� U I 9 7C�
Narnz(Print) Ciry,Statq ZIP
i G�1 y� �.. T' /,�r� 975�•Sf53 t�y7.�
No.and Street Telephone Email Address
SECT[ON 3: DESCRIPTION OF PROP05ED WORK''(c6eck all that upply) .;.
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Dzmofition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
D Brief Description of Proposed�Vork2: � L� �—��Ut�R .S /� � �i�/�!�N /� w� Y_l l�il�y'Nt
/I��w l.rC.i•i �� J"ixTu:Z.t-�' o SfiMN /5�� 2jnc �Gn�..:i LJe .r, ✓.1vcu,J' •
N�uJ f.( ) rCiiiw �^Y� r�� � r—T�' ; Sr-lC�r Roe.�� J j=Lve�.2 l�E�Li'w
SECTION 4: ESTI�'Ir1TED CONSTRUCTION COSTS .
Item Estimated Costs: Official Use Onl
Labor and �faterials y``
1. Building � 1. Building PermitFee $ ' IndicSte How fee is determined:
2. Flectrical � ❑ Standard CityYCoWn Application Fee
� Total Piv�ect Cost''{Item 6)x multipl(ar x
3. Plumbing 'S � OtherFees: � ��
l. �[echanical (FfV;�C) ) List _.(,/__�1�
5. \-[zch:mical (Fira �
'iippression) I'utal.�\ll Fees: S
Check No. Ctieck Amoimt: Cxsh Amounr.
(,. "Cuf:�l Prnjcct Cost: $ f� 'J�(� -�� ❑ Paid in f ulf ❑ Outstandin� �
_ 13alancc Duc:
�� � �L�`�'U�
�
SCCCION 5: COYSTRUC"C(OY SERVICES
S.l Cm�struction Supervisur Liccnse(CSL)
License Number B.epiration Date
Name of CSL Floldcr �
List CSL Type(see balow)
No. and Strzet Type , ��� � � Description .
U Unrestrictzd DuilJin�s u to 3i,000 cu It.)
R Rcstrictcd f.4e2 Famil Dwellin
City/�Po�vn, Statz, G(P y V( �4asonr
RC 2au6no Caverin
NS WindownndJidin '�
� SF Sulid Futl L3uming Appliances
[ Insulation
'felz hone Email uddress D Demolition
5.2 Registered Hume ImprovementContractor(FI[C)
HIC RtgisVation Numbtr Espirutiun D�te
I�IIC Cumpany Name or FIfC Rtgistrant Name
No. and Street Email address
Ci /Town, State, ZIP Tzle hone
SECTION 6: WORKERS' COMPEYSA'CION IIYSURANCE AFFIDAV[T(M.G.L,c. 152. § 25C(6))
Workers Compensation Insurance aFfidavit must be completed and submitted with this application. Failure to provide
diis affidavit will result in the denial of the [ssuance of the buifding permit.
Signed Affidavit Attached? Yes .......... ❑ No ........... ❑
SECTION 7a: OWNER AUTHORIZATIOIY TO BE COMPLETED WHE�Y
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDIYG PERM[T
[, as Owner of the subjzct properry, hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit xpplication.
Print Owiter's i 11ma(Electronic Signature) D�te
SF.CT[OY 7b: O�VNER� OR AUTHOR[ZED AGEN'C DECL:\R.4TIOY
By entering my name below, [ hereby attest under the pains and penalties of perjury that all of the inform�tion
� cont ined iii this applicati n is true and aceurate to the best of my knowledge and underst�nding.
�j�`IL�/�L I�L� ��1 _ � '- .� �-1.�
Print O�vn� 's or Autltorized:\�tnt's Namt(Electronic Sign�ture) n�1tz
YOTES:
I. An U�vner whu ubtains a building permit to do his/her uwn work,or an uwner who hires an unregistered contractor
(nut registzred in the Homz Improvemznt Contractur(HlC) Program),will i�n[have aceess tu the ssrbitration
progr:un or gttaranty fund under DLG.L. c. 1�2A. Other important infurmation on thz H[C Program can be found at
�o�vw.inass.�,o�%ora Infbrmation on the Construction Supervisor License c�n be found at w�vw.mas;.�zo�"dL
2. Nhen substantial wurk is planned,provide the information beluw:
"futal ftoor area(sq. tG) _(incfuding garagz, tinishzd bnsemendattics, decks or porch)
Gro;s living;vca (sq. ft.) _ _ Habitable roum coun[
Nnmberutfireplaccs _ _ NumbarotbcJrooms _ --
Ninnbcr of badirooms Vuinber ot h;ilf/baths _
Type uFhc;�ting systcnt _------ Numbcr of dacks/purchcs .---- --
Tti'peufcoolin�sysirm__ --__— _ G.nclo;cd—_ ----Opcn- —
>. __I'ot_.il Pniject Syunre I_oot:i�c" inay be sub�titute�l t;u_`"G�tal Prujeet Cust" -
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,.:;r ti CITY OF S��LEI�t, �L-1SS.�CHL'SETTS
� }�'�` {,^ r, Bc:u.n�c DEpnxr��vr
•.. 't�,t'�",o;�. ,• 130 VUASHCYGTON STREE "�
� T, 3 FL.00tt
"I�L (978) 735-9595
KI1iBERLEY DRISCOLL
F.ti�c(978) 7-1Q9846
:LL�YOR "TT-iosus Sr.PLsxae
' D(.QECTOR OF PI:HLiC pROPEATY/BL'ILD4�;G COtplJ55IONER
' C'onstruction Debris Disposal Affidavit .
(required for all demolition :uid renuvation work)
1n accordance with the sixth edition of tlie State Building Code, 730 CMR section l l 1.5
Debris, and the provisions of;�1GL c 40, S 54;
Huilding Permit ik is issued with the condition that the dcbris resulting &om
this worlc shall be disposcd of in a propzrly licensed waste disposal Facility as defined by NiGL c
111, S ISOA.
1'he debris will be transported by:
C�l /C. � �s��'r~S '7i_���C !� L
(namcufhaulcr) � — - �
'I'he debris wi11 be disposed of in :
I (namc of facilitY) ' ..,
_��,,,_l�_7SJ-_y q , I
� (�(�f�l'CSS D�I��I�iIY� ' ' I
f I
siy amre of permi[applicant
date
�Icbn:;a�(.J.w .
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A. __ _ __' __ . —_ . __ . _ _. __ _ '_ — _ .. __ ..
r,!7
Plesw "I
CITY OF S.u.E.M
PUBLIC PROPERTY
DEPARTMENT
I -s WM Mw7oMsaver • ULM vns4owTimolt•e
r1a. VV45.9s" • FAX 93.740.9e+e
HOMEOWNER LICLNSS EXEMMON
Date 1-�a-]3
Job Location I Cry: r
Home Owner Address _
Home Owner Telephone
Present Mauling Address
no current exemption of "Homeowmrs" was extended to include owmroccupied
dwellings oftwo Unite or les and to allow such bomeowoers to engsge an individual for
hire who. does not possess a license 4 provided that the owner acts as supervisor.
DEFWMON OF HOMEOWNER
Persons) who owns a patenl of land on which halsbe resides or Intends to resider, on
which thane is, or is intended to be, a one or two Ihmily dweilfns attached or detached
structures accessory to such use and/or farm structures. A person who contracts 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 hNshe understands the City of Salem
8WIding Department minimum inspection procedures and requirements and that hdshe
Will comply with said procedures and req irements.
HOMEOWNERS SIGNATURE
\PPROVAL Of alUDNG NSPECTO
Sce other side far state code