22 GREEN ST - BUILDING INSPECTION (2) x-b Che Commonwealth of Massachusetts CITY OF
Board of Building Regulati n a�n Prnrcidara QED
9i y � rt�`1 � . SERI F SALEM
Massachusetts State Building od , 80 GMR .to ,C $ Revised,liar 2011
Building Permit Application To Construct, Rggpp��+tr,�g�tt�Ste A Demolish a
One-or Two-Family Dfiv'e71
This Section For Official Use On
Building Permit Number: I Date pplfed:
O
Building Otlicial(Print Name)
SECTION I:SITEINFORV1AT10N.'
LI P�operty Address: 1.2 Assessors flap&Parcel Numbers
- ra'Y C/'7 1111�-
I.I a Is this an accepted street9 yes_ no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq t1) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yams Rear Yard
Requirod Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.Q,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑
SECTION2. PROPERTY OWN ER SHIP"
2.1 Owner of Record:
}� throe(Print) City,State,ZIP
c2 & rG3 6 0 0 'o ®j
No."rod StreetTelephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repaus(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work-:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
(tent Labor and Materials) -
I. Building $ �Q "�yJ I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard Cityllbwn Application Fee
2. Electrical S ❑Total Project Cost?(Item 6)x multiplier x
3. Plumbing $ 2�Qther Fees: .S Jy�
4. ,Mc hanical (11VAC) S List: �rJ vim-'
5. Mechanical (Fire 3 Total All Fees:S-
Sup ression)
Check No._Check Amount: Cash Amount:
6. 'rotai Project Cost: .T 3 D- `s J 13 Paid in Full 13 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Dale
-
Name of CSL Uulder List CSL Type(see below)
Type' - Description
Nu.:mJ Street - __
U Unrestricted(Buildings tip-to 35,000 cu. Il.
R Restricted 1&2 Family Dwelling
Cityfruwn,State,ZIP M Masonry
RC Rooling Coverin
WS Window and Siding
SF Solid Fuel Burning Appliances
1 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'CONIPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 2SC(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 Isivance of the building permit.
Signed Affidavit Attached? Yes ..........❑ No...........❑
SECTION 7a-OWNER AUTHORIZATION.TO BE.COMPLETED WHEN, :,
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUIGDINd PERMIT
i,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
A
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW ORAUTHORIZED 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 Irue id accur to to the best of my knowledge and understanding.
Print Owner's or Authorized Agen�Name(L�nic afore) Date
NOTES:
I. An Owner who obtains a building permit to Jo his/her own work,or anowner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program);will no have access to the arbitration
program or guaranty fund under II.G.L.c. I42A.Other important information on the HIC Program can be found at
mv%v niass. goL y;20 Information on the Construction Supervisor License can be found at wwuv.mass.��ov%'J,=,_L .
2. When substantial work is planned,provide the information below:
rotal floor area(sq. R.) 's .(including garage,finished basementlattics,decks or porch)
Gross living area(sq. 11.) - Habitable roam count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
'type orcooling systo❑ Enclosed Open
J. Total Project Square Footage" may be substituted fur"Total Project Cost'
CITY OF SALEM, MASSACHUSETTS
3 , , BUILDING DEPARTMENT`
120WASHINGTON STREET,3" FLOOR
TEL. (978)745-9595
n_ = FAX(978)740-9846
KIA BERLEYDRISCOLL
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLICPROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date 9—/9-cgs M—
Job location C_. Grp e-7 59
Home Owner Address ou �✓ v� S,)�PtvS /�lit�
Present Mailing Address XR G✓�eeH
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 that 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 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 �d�i Cir
APPROVAL OF BUILDING INSPECTOR
CITY OF SALEA MASSACHUSE M
BuuDUJc DEPARTAaw
120 WABtDNG70NS7MT,3IDFIooR
UL(978)745-9595.
KIWERLEYDRISODLL FAX(978)740-9846
MAYOR 7)i r STJIIJEM
DIREcroxorPmucrxomm/Bi [mmoDmmoNER
Construction Debris Disposal Affidavit
(required for-all demolition and,renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, S 54; Building Permit is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
Date