12 GREEN ST - BUILDING INSPECTION �ZSSO
=K (a9 � 1
S\ The Commonwealth of Massachusetts RECEI ED
-{ Board of Building Regulations and Standards MPECTIOH SE,SALEM
Massachusetts State Building Code,780 CMR SdMor
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or AWN P E> 04
One-or Two-Family Dwelling
This Section For Official Use Ouly
11 Building Permit Number: - D4Applied: -
Nun•' o� h
f -Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Addre 1.2 Assessors Map&Parcel Numbers
1
l.la 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 it) Frontage(it)
1.5 Building Setbacks(it)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: �^
n C Gi ryi. 0 At�•� C �.�1cT S o�� vh / Nl W o
Name(Print) City,State,ZIP
� a, Gc—ee ^ q -7 9 - -766-79aS
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ i Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Pro osed Work2:
7� f`J r S ���
7\ SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 3 20 O 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'. Itcni 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ - -
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 32-D D ❑Paid im Full ❑Outstanding Balance Due:
MPt �� i0 �2�
SECTION 5: CONSTRUCTION SERVICES +
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Farm] Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town, State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATTON 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&.nmer of the v-,bject 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 7b:OWNERt 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 Wthbest of m?L.knowled a and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) 1=U L Le:: �f W Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
wtivw.mass. oK v;oca Information on the Construction Supervisor License can be found at w�ov/dam
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 area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halffbaths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
MORTGAGE INSPECTION PLAN
BOSTON
Y 11-04099
SURVEYS INC.
P.O.Box 290220 Charlestown,MA 02129
(617)242-1313 MAIN (617)242-1616 FAX mpp0bostonsursheyinc.com
APPLICANT: DIANA M.ROSENBAUM FULLERTON DEED/CERT. 20302-231
LOCATION. 12 GREEN STREET PLAN REF.
1 inch=20 feet
E
CITY, STATE: ALEM, MA PREPARED: 06-01-2011
CERTIFIED TO: ASTERN BANK
� re
j.
u.
#12
2 STORY
}
PORCH
-
GREEN STREET
my(q eastaa s„rver wn.a�e LOT CONFIGURATION BASED
ON ASSESSORS MAP
.J INSTRUMENT SURVEY RECOMMENDED
The permanent structures are approximately located on the WA%A OF MASS4 * Accurding to r deral Emergency Nfe r.,ement Ageop,
ground asamw..Theyeither conformed..the setback ��Q C���mape,the major impmvcments on this pmpe ny fall loan
requirements mf the Incal song faro ounces n effect.., O GEORGE S
the time ofwnstrucuon.or are exempt from eiolmion D, area de,ugnaredas Zone.
adurtemem acunn umlerMGl Tide Vfl,Chaper OOA COLLIN$ m 4.Commtnlly Panel No
Section'7,and(hat eherem, mennofmajor 0.
47)gb � "y"
'm rovcmentscrther way as Y p LHative Uaur S4 h.-i - "�
l p y acre prif," Imes ea t as o9 v
shown and noted hereon C9 OFF -.J NOTE Zone C is areas of minimal Flooding(no shading).
NO This designation is not based on an elev ce ation dibcate.
NOTE:Th an is not a boundary a rate insurance survey.This plan was once to procedural and technical standaMs for Mortgage Loan Inspections as adopted
by the Massachusetts Board of negslralifan t pralesslorm!engines and lard surveyors,250 CMR 6.05,aM use for any f tner purpose IS po0hihlli Thli plan Is not face
used In,recording.prepadas,deed descriptich,or conslmchon.
aCITYOFSALEMMASSACMETTSBUILDING DEPARTMENT4 120 WASHINGTONSTREET,3x FLOOR
TEL. (978)745-9595
KIMBERLEY DRISCOLL FAX(978)740-9846
MAYOR T}-IOMAS STTIERRE
DIRECTOR OF PUBLICPROPERTY/BUILDING COMI&SSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date ti D l ZZ1 (�> \
Job Location la G t-�el^ SA, , S%le.�., M ���
Home Owner Address S°u
Present Mailing Address
The current exemption of"Homeowners"was extended to include owner-occupied dwellings of two
Units or less and to allow such homeoanmers to engage an individu,31 fr,r hire that does not possess a
license, provided that thiowner acts as supervisor.
DEFINITION OF HOMEOWNER f
Person(s)who owns a parcel of land on which he/she resides or intends to(ieside, on which there is, or
is intended to be, a one=or two-family dwelling, attached or detached stru4 tures 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 understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR