28 GROVE ST - BPA B-2012-0585 aka B-2012-628 7 1'he C'ununonsce;dlh of M:usachuuus _
Board of Building Regulations and Standards CITY OF
s(L , Massachusetts Suite Building Code, 780 CNIR SALEM
=+ Re ri.rad.I fur
Building Permit Applieation 'ro Construct, Repair, Renovate Or Del tolis u
One-or Tire-Fumilr Dn elling
This Section For 011icial Use Old
Building Permit Number: _ Da Ap •d: _
/ ► 77 IZ
Uwlding( tiicial i'rint Marc) f goal One
SECTION I:SITE INIFORMATION
Property Addrns: 1.2 Assessor Map& Parcel Number
�fi G-rrn�a r-j-
1.1 a Is this an acre ted street?yes no Map Numhcr Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District I'ropoxd the Lot Area(s4 11) Frontage(II)
1.5 Building Setbacks(R)
Front Yard Side Yards
Rear Yard
Required Pruvided Required Provided Reyuircd Provided
1.6 Water Supply:(M.G.L c.40.S 54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Munici el❑ On site disposals)Check if vs❑ P posal s stem ❑
SECTION 2: PROPERTY OWNERSHIP'
2. wnerI of Rec rd:
Ph,/t, 9w € Z44-t`( /
N:une(Print) (ay,State,! /
2 Yoe
ofwe- 1� G'f 7- ? 74-�3 5� barlc/a o 7
� v
No.and Street Telephone Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied O I Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Denwlition ❑ Accessory Bldg. ❑ ero Unih_ Other ❑ Spccil'y:
Brief Description of Proposrd Work=:
lLerlo� vv� mot✓ NPR 4 one
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and.Materiais) Official Use Only
1. nuilding S I. Building Permit Fee: S Indicate how fee is determined:
tilectrical S O Standard City?uwn Application Fee
❑Tutnl Project Cost'(11em 6)v multiplier
t, Plumbing S '. Other Fees: S - ---—
4. \Nchanlcal 111 %('1 S List:
Cu+ucssion) S Total \II Fees: S
Check No. ('httk :\nt+nutl: (',Ish \m+nm1: I
n. TuIrII'tvtjcctCnst: i � ---- —._.._-
f/d( ❑ Puid in Full 0 Outstanding B:d:mce Due:
SECTION 5: ('0NSFRU(-rio,,4 SERVICTS
5.1 Construction Supen,isor License(CSL)
I \piratioii Dole
Nanic,,ILSI 11older I is 01.
Na. and Slrcct
I)pc
(I I
R Retrivtcd l&,2 Famill lAwlill'a
kI
RC 4i!,;,�E70,vvring
WS Windm% iind Siding
SF Solid Fuel llurning Appliances
I
Mhuulution
'Felt Fniail�addrcsi D Demolition
'I Contractor(1110
5.2 Registered flume Improvement Contractor(HIC)
111C lIcSibinition Number Expiration Dutc
I lIC Compin) Name or I IlC Registrant Name
No. mid Street Etnuil uddross
City/Town.State,ZIP Tcle hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152.1 ISC(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 ..........E3 No...... 0
SECTION 7a:OWNER AUTHORIZATION TO BE ZONIPLETED 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(Elcorunic Signature) Date
SECTION71s:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contain
ontain n this application is true a accurate IQ the best of my knowledge and understanding.
oAd
Print Omwr*i or Name ffle"ronic Signature) Date
NOTES:
I. An Owner who o obtains a building permit to do his,her own work,or an owner who hires an unregistered contractor
(not registered in the Hume Improvement Contractor(HIC)Program).will t Uo have access to the arbitration
program or guaranty fund under.M.G.L.c. 142A.Other important information on the HIC Program can be l'ound at
\%\%\% ot.i information on the Construction Supervisor License can be found at%% mm,; �;!A .111,
2. When substantial%wrk is planned• provide the information below:
rotai fluor area(i+ n.) I including garage. finished basenlent.attics,decks or porch)
Gross li\ingarca I s4. it I Habitable room count
I I \umber of fireplaces Number of Bedrooms
Number o(decks, pordies
Enclosed
------------
lie subittutcd 1'or-l*otal Project Cost"
CITY OF S.U.ENf
PUBLIC PROPERTY
DEPART N, LENT
u,s�o�emtl
Nwrae �sow�ue,,ow sn.ar•swat�ba�owanf etf'0
nL rs-745-1s" •FAX 978,14o.98"
HOMEOWNER LICENSE EXEIMMON
Please Prier
osa
Job I:aeatias 2 C21V C
Home Owner Addhresa Yr c t v g- s f-
HomeOwner?elephone '2 ( -7-ea 7d 27
Presort Muting Address 2 g 77u Q-
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
hire who.does not possess a licenser provided that the owner acts as supervisor.
DERNMON W HOMEOWNER
Person(s) wbo owns a parcel of land on which halsbe resides or intends to residej on
which them is, or is intended to be, a one or two family dweW S attached or detached
structwes accessory to such use and/or farm structures. A person who constructs mars
than one home in a two year period shall not be considered a homeowner. Such
"homeowner"shell submit to the Building Official,on a form acceptable to the Building
Official, that helshe be responsible for all such work performed under the Building
Permit
The undenigned "homeownd'assumes responsibility for compliance with the State
Building Code and other applicable bylaws and regWadonL
The undersigned "homeowner"certifies that he/she understands the City of Salem
Building Department Minimum inspection procedures and requirements and that he/she
vill comply with said procedures and r sir
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF S.1LEM, .tiL1SS.kcffL:SETTS
BLtt.DLNG 0EP.1ATM%-r
I'0 W.IjHLVGT0m STRt B'f, jw FtOOA
TIM (978) 145-9599
KIMBEA FsY ORLSCOLL FAX(978) 740-9846
MAMA THo.►W SLFiEAAs
DIAECTOA OP Pl'BtIC PROPEATY/8""NG C01011SS10N EA
Construction Debris Disposal Attldavit
(required for all demolition and renovation work)
In accordance with the sixth edition arthe State Building Code, 780 CMR section 1 I I.J
Debris, and the provisions of MGL a 40, S 34;
Building permit M is issued with the condition that the dcbris resulting from
1, S I JOA.
INS work shall be disposed of in a properly licensed waste disposal facility as defincd by NIGL c
11
The debris willl�bee'transported by:
O cT� Vi'ca/� �cT
(name of Aeuler)
The debris will be disposed of in
(nime oe
(Jddrarr of rjtl;11, .)
IynaNreofpermlf�pplwm( C�
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