10 GREEN ST - BUILDING INSPECTION The Commonwealth of NIassuchLISCUS
r ' 13ourJ of 13wlJing RcguLmons and Standards ?Il'Vlt llllt\I.I I l
_7 M:ISSaIhLISCUS Stale 11,111ding Code. 7S(I CNIR, 7"' edition I '.Sl_
Building Permit Application To Construct. Repair. ReY10%ate Ch Ucmoli.h a R rnd./ uutu j
Oil(,- nr Tit a-/amdv Du t'llinx 'uu5
This Section For Official Use Only
Building Permit NuMM': _ Date Applied: __ -_----
Signal urea rL% __ � - ----- ------- - -
i f mg.Comuu„wi / Inspector of Buildings --
✓ SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map & Parcel N u3u s
_ U rc sT _`9�`--
I la Is Ihi, :m accepted street:' ses,�uo Map N'unther I'ar.d Nunihcr _ J
1.3 "Zoning Information: L4 Property Dimensions:
1,/Uo V s�
Zoning District Proposed Use Lot Arca (sq li) F7uwage ilt)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear lard
Required Provided Required Provided 12equned PI'o\1&d
1.6 Water Supply: (M.G.L r. 40• §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Puhlic U/ Private❑ Zone: _ Outside Flood Zone"
Check if yes❑ Municipal M/'On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP!
2.1 Owners of Record: /
�E-crQle E —
Name I Print) Address for Service.
Sienature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK' (check all that apply)
New Construction ❑ Existing Building IT Owner-Occupied ❑ 12epairs[s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work-: e F/AAJC"E /C/.(1(nS C)nl i" y&)
i v A n - c c cx P I �'14 RA-D on 7 /le6:G 2r�l7
)2 1. O it r PFc(Sr=
SECTION J: ES'rIMATED CONSTRUCTION COWS
Estimated Costs: Official Use Only
Item (Lahor and Materials) ---
1. Building 'S I. Building Permit Fee: S ' ndicate how, fee is deter nulled:
❑ Standard City/Town Application Fee
2. Electrical S ❑Total Project Coati ([tern 6) x multiplier x _
3. Plumbing 3 2. Other Fees: $
q. Mechanical (M AC) $ List: ---
i
5. Mcchanical (Fire
Su)ncasnn) Total All Fees: $
Check No. Check Antnunt: 2f' Cash .-1mInun j 0, Total Project CosC S L /(go °J �
aid m Full ❑ Outstanding Bal,1aCC Due__-- ---
i
SECTION 5: CONSTRUCTION SERVICES
5.1 I-icensed Construction Supervisor(CSL)
License Number Pxptrati(1n Date
Name of CSL- I lolder
Li.,i CSL Txpc tree below)
"I'v)c Descri lion
lddrcs 1. 1,nrestrtcted o')to .,) (,010('u. Ft.t
R Resni,ted i&' Fanuls D\\elhn_
Signature Al Al;uonn Unly
RC Residrnual Roufne ('u\rnng
'telephone N'S Itc>Idcnu:d AVI ]JI1y1 .md S1,1111 _
St Rcmdeuted .S�Jid Fuel Burnuu \ +di.mCC ht.t.ill.w".0
D Rc,Idenli,d Ih•nwhunn
5.2 Registered Home Improrernenl Contractor (IIIC)
IIIC Company .N:une or HIC Registrant Name Kcgutratiun Number
Address _
Expiration Date
Stgnmure relephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(NI.G.L. e. 152. § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Fadure 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
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.
Signature of Owner Date
SECTION 7 : OWNEW OR AUTHORIZED .AGENT DECLARATION
c> �
a Owner Authorized Agent hereby declare
rhut the state gents and intorrnation u e foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print NA
Signature of"Owrt r }Authorized . gent Date J
(Signed un c -aini and penalties of cru
NOTES:
1. An Owner who obtains a building permit to du his/her own work. ur ❑n owner who hires an unregistered conuannr
(not registered in the Home Improvement Contractor jHIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142 A. Other important information on the HIC Program and
Construction Supervisor Licensing (CSI-) can be hound in 780 CNIR Regulations 110.R6 and 1 I0.10, respecii�ely.
' When substantial work is planned, provide the information below:
Total flours area (Sq. Ft.) (including garage, finished basement/anics, decks or porch)
j Gross living urea t Sq. Ft.) Habitable room count _
Number of fireplaces Number of bedroom,
Number of btuhnnmts Number of h:dt/barhs
Type of heating system Number of decks/ poiChcs
'type of Cooling System Lncluned Opcn --
i. 'Total Project Square Footage" may be substituted fin Total Project Cost—
'1
CITY OF &UEM
PUBLIC PROPERTY
DEPARTMENT
Kl?ME�IIsY ruw-,v
130 WANONGTON SMELT•
•,eu MASfAolt:5ETTS 019T0
7Ei 978-7454S"• FAX 972-740-98"
HOMEOWNER LICENSE EXEMPTION
Please Print
Date
Job Location /U
Home Owner Address i O ST
Home Owner Telephone 9 7 Y- 7 VV S-9 S41
Present Mailing Address /O G,C-c—� s'T S r�
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 who.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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requi ements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR z
See other side fo
r state code
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
l_.
'fit it\C:J�SacfT • SA;:
CFI. v78-I45-)595
Construction Debris Disposal Affidavit
(required fur all demolition and renovation work)
In accordance w ith the sixth edition of the state Building Code, 730 C`1R section 111.5 1
Debris, and the provisions of NiGL c 40, S 54;
Building Permit p _ is issued with the condition that the debris resulting from
[his work shall be disposed of in a properly licensed waste disposal facility as defined by V1G1. c
111, S 150A.
The debris will be transported by:
'name of h ler)
I'L'c ,!�:bns will bedissp'osed ofin :
l o.,me �f fa�da