39 GROVE ST - BUILDING INSPECTION �✓l ,� /i/�,c P V
S The Cummon%calth of Massachusetts Town of
Board of Budding Regulations and Standards
Massachusetts State Budding Code, 780 CMR, T"edition Building Dept
Budding Permit Application To Construct, Repair. Renovate Or Demolish a
twoodoo
One. or Tvo-Puntilt-Duefl/ng
This Section For Official Use O
Budding Permit Number: Date Applied' /
Signature:
Budding Commissioner/Intprctor of Bwldmp D
I�py�rra�yy a� SECTION 1:SITE INFORMATION
1 5 7 C�2U(/f� 11 Assessors Map i Parcelnf4umb1.la Is this an ace ted street''yes no Map Number 1../ Zoning Information: I.d Piopsrry Dimensions:
Zoning District Pr posed Use Lot Area(sq R)
1.5 Building Setbacks(It)
Front Yard Side Yards Rear Yard
Required Provided Required Providedf1.9
Required Provided
1.6 Wooer Supply:(M.G.L c.40.154) 1.7 Flood Zone Information: Sewsgt Disposal System:
Zone: _ Outside Flood Zone? Municipal¢ On site disposal system O
Public ffi Private O Cheek if sic)
SECTION 7: PROPERTY OWNERSHIP"
2.1 DwnerlofRecord:
rn irD.rvt.-1
Name IPnnq Address for Service: '
Signs Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK"(check ad that apply)
New Construction O Existing Building� Owner-Occupied C Repairs(s)`II Alteration(s) O Addition O
Demolition O AccessoryBldg.O NumberofUnits_ Other O Specify:
Brief Descriptionn of Propgsed Worka:
SECTION d: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Offlelal Uae Only
05.Mechanical
Labor and Materials
g f 1. Building Permit Fee: f Indicate how fee is determined:
O Standard City/Town Application Fee
cal f O Total Project Cost"(Item 6)x multiplier x
ng f 2. Other Fees: f
cal (HVAC) f List:
cal Ifire S Total All Fees:nOG) Check No, Check Amount: Cash Amount:_roject Cost f / �0� C pad m Full 0 Outstanding Balance Due
SECTIONS: CONSTRUCTION SERVICES
!.I Licensed Construction Supervisor(CSL)
• Lireme Number Expiration Djte
ryror of CSL Ilplda Li+t CSL Type(xro he low)
A i
Address T Description
U Unrestricted(up to 11.000 Cu Ft
R I Restricted 1&2 Family Dwellin
SigMlure N %fasonry Only
RC Residential Roofing Covering
Telephone w'S Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. ISL# 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 A171davitAttached7 Yes..........0 No...........O
SECTION Its: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.
Signal=orowner Date
//^^ SECTION 7b:OWNERS OR AUTHORIZED AGENT DECLARATION
1, / /Ux✓Y iZJ Aax4&U as Owner or Authorized Agent hereby declare
that the statements and information on foregoing application arc true and accurate,to the beat of my knowledge and
behalf.
Gd�l� v
Trim Name
�2, -1Z—!O
Sipplifure of w Authorized Agent Date
(Siwiecl under the pains and penalties of
NOTES:
I. 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 gg have access to the arbitration
program or guaranty fund under M.G.L. c. 1 o2A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL►can be found in 780 CMR Regulations 110 R6 and 110 RJ,respectively.
2. When substantial work is planned•provide the information below
Taal noon area(Sec. Ft.) (including garage. finished basementiantcs,decks or porch)
Gross living area(Sq. Ft Habitable room count
.Number of fireplaces Number of bedrooms
Number of balhrooms Number of half.baths
Type ofheming System Number ofdecksr porches
T.peof cooling vysiem Enclowd Open
1 -Tool Project Syuare Footage"may he+uhstituted for 'Total project Co%C
CITY OF SALE.NI
PUBLIC PROPERTY
DEPARTtiIENT
IV l�Y NM.'IY 1
rm rs-715-9s"0 F.ui.978-74&9W
HOMEOWNER LICENSE EXEMPTION
Pkaw Triat
Date
Job Location' (9Rooe-- Ski LlJ'W'I
Home Owner Address- GRou,- g7
Home Owner Telephone �Z 435-6
—
Present Mailing Address % r,on Grr 5- ' S/a A
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
Persons)who owns a parcel of land on which he/she resides or intends to reside, on
which them 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"assume 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 requirem
HOMEOWNERS SIGNATURE
,APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SALEM
r- &-7 PUBLIC PROPRERTY
DEPARTMENT
IUI1: sit) !•nlw"I 1
,a I fit?VI'.\il ll.\G:PV)1'NEri S.\I I M, MAi"t III
fF1:WV—'43.95t)5 ♦1°.%x:979-740.9846
Construction Debris Disposal Affidavit
(required lour 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 c 40, S 54;
Building Permit is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I 11. S 150A.
The debris will be transported by:
t name of hauler)
The debris will be disposed of in
I (name olTacl ltyy)
laddress of t lcilily)
u urc of wrmit applicant -
(late
Ichn vil' : .