72 GROVE ST - BUILDING INSPECTION (2) S ,
30q - I ua"5H Oc)
The Commonwealth of Massachusetts CI"rY OF
l Board of Building Regulations and Standards
Massachusetts State� Building Code,780 CMR SALEM� Revised.Clot 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date.Ap ed.
2r /d/9//
Building 011icial(Print Nmne). Signature - Date
SECTION I:SITE INFORMATION
/A LI jfsy rty �s: ���e 1.2 Assessors Map& Parcel Numbers
L a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 'Coning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq Ill Frontage(R)
1.5 Building Setbacks(ft)
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 ifyes❑
SECTION2: PROPERTY OWNERSHIP"
2.1 wn t of Record•
NN4anc(Print) a City,Slate,ZIP �—
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work'-:
�YYto1 P C��-1'�d GL/n �✓ T 6�9�
SECTION 4: ESTINIATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and iNlaterials)
I. Building S I. Building Permit Fee:$ Indicate how fee is determined:
�. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $ n1 `"— (
4. Mechanical (FIVAC) S List: �
5, ,Mechanical (Fire S Suppression) 'rota)All Fees:S
Check No._Check Amount: Cash Amount:
6. Tohtl Project Cost: S 0 Paid in Full ❑Outstanding Balance Due:
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. It.)
R Restricted 1&2 Family Dwelling
Citylruwn,State,ZIP NI Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
rele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
111C Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION 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"
1,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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION-
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
ri..t Owner's or Authorized i gent's Name(Electronic Signature) Dale
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 not have access to the arbitration
program or guaranty fund under NLG.L.c. 142A.Other important information on the HIC Program can be found at
www.rnass.eov'oca Information on the Construction Supervisor License can be found at wkew.mass.''ov:/dns
�. 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 half/baths
Type of healing system Number of decks/porches
Type of cooling system Enclosed Open
1. "rotal Project Square Footage"may be substituted for"food Project Cost"
is .
CITY OF S.0 &Nf
PUBLIC PROPERTY
DEPAM4 LENT
VUwurOWMA"
VAYM
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HWHEOWNER LICENSL E.U.ti1p'I'IOlV
Plesse mat
Date J
lob Laud" 7.GaI
Home Owow Addtear
Home Owner Telepboew
Pnwmt Mailing Address
Tbs tureens esemlidcs of"HomeowMe was Wended to include owns-occupied
dwellings of"Units or leas and to allow such homeowners to engage ao individual rat
hire who does not poaaets a Itee114 provided that the owner acts as aupaWsm
DPJlN ION OF HOMEOWNER
Pawn(s) wbe owns a pared of 1AW as which hdsbs resides or intends to redder on
which there la, or is Waded to bel, a oce or two lhmily dweWng athrched or detached
,avenues Wccssory to such use and/or rum st Wftarea A person who constnuta more
than erne home is s two year period shall not be considered a homeowner. Such
"hameowner�'sW submit to the Building OQleiak an a form acceptable to the Bwldin;
Permit that helshe be responsible for all such work performed under the Building
The undersigned "homeownce 1+sumes responsibility rot compliance with the State
Building Code and other applicable by-laws and rcguladons.
no undenigned"homeowner"ceniRes that he/3he undentands the City of Salem
GBuilding Oepartment minimum ia3pecrion procedures and requirements and that hd3he
.vill comply with said procedures and requirements,
HOMEOWNERS SIGMA rL RB
kPPROVAL OF BUILONG 4VSPECTOq ,
Set other Side for state coda
.' CITY OF SAL.EM, NIASSACHUSETTS
BuiLDLNG DEPARTMENT
• P 120 WASHINGTON STREET, 3" FLOOR
TEL (978) 745-9595
Rim(978) 740-9846
KI.,%IBERi FY DRISCOLL
'AAYOR THo.%w ST.PtEm
DIRECTOR OF PUBLIC PROPERTY/BUIMLNG CO\pIISSIONER
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 c 40, 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 disposal facility as defined by MGL c
111, S 150A.
The debris wiH be transported by:
ct6
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit applicant
date
IcbrisIf:Jx
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n
wiM• +�- -N•.. s .. T °A^a $s � F _ s
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