72 GROVE ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised.11ur 2011
Building Permit Application To Construct, Repair. Renovate Or Demolish a
Our-or Two-Fanid.V Du ellinq
This Section For Official Use Onl
Building Permit Number: Da Applied:
Building Official(Print Nwne) Signature Date
SECTION 1: SITE INFORMATION
1.1 o erty Address: 1.2 Assessors NVtap St rce u rs
1.1 a Is this an accepted street?yes_ no Map Number P• cel Number
1.3 Zoning Information: LJ Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(11)
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?Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY NERSHIPt
2. w ern of Record:15 — / y
Nwn•(Print) r CUty.S1 .LIP
&Z;7's -yG1 111)_
No.and Street ` ' Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brie fDesc;iptionofProposed Works: ,IG,.(4/;,) ,lf117 ,�• n e
r ai n pr . K JL4s- t
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Itcm Estimated Costs: Official Use Only
(Labor and Materials) y
I. Building S 1. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost l Item 6)x multiplier _ x
?. Plumbing S 1. Other Fees: S
4—Mechanical tll\.\C) $ List:__
s \Icchanie:d (Fire — ---�------
ession I S Total .\II Fees:S
Su�,Lr _
Check No. _Check:\mount: _ _ C;uh :\mount:
6. Total Project Cost: 5 a I a// ❑ Paid in Full ❑Outstanding Balance Due: � _ -
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(C'SL)
License Numberf_cpiratiun D:ue
N;une of l'SI. I luldcr
List CSI.1)pe(see below)
No. and Street Description
l! l Inrestricted(Buildings up to 35,000 ca. 11.)
It Restricted 1@2 Family Dwellin
C'itN form,Stine,ZIP M Nlasontj
RC' Rnulin C'ovcrin
W'S W'indutr and
Sid in
SF Solid Fact Burning Appliances
I Insulation
'I cle hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
IIIC Registration Nuntbcr ILspiration bate
I IIC Company Name or IIIC Registrant Name
No. and Street Email address
City/Town.State, ZIP Mc phone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 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 7s: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,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 Nwne(Electronic Signature) Date
SECTION 7b:OWNEW 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 i is application is true and accurate to the best of my knowledge and understanding.
Prim Owner's or:\uthorized Agent's Name(Plectrunic 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 M.G.L. c. 142A.Other important information on the HIC Program can be found at
tutts Information on the Construction Supervisor License can be found at y��tt_mpagyn dp,
2. When substantial work is planned, provide the information below:
Total fluor area (sq. ft.) _--_I including garage, finished basement'attics,decks or porch)
Gross living area 1 sq. 11.l - -_ Habitable room count _
Nuniber of fireplaces `umber of bedrooms
Number of'hathrooms Number of half hallo
F pc of heating system _ _ . .._. _ _ _ `umber ot'decks, porches.
o
I')Pe f ending sy Stem ... _. __- _- unclosed -open
1. -Foial Project Square Footage"nlay be SUbstiuncd fitt•`rota) Project Cost-
f.
CITY OF S.ux.%Vf
PUBLIC PROPERTY
DEPARTMENT
u,a.a�sr o..r•.r 6
VArae 135 WAYYMCTC Maxt 6 4g,— AUL O&stM 01 OV.
1$r4745-75" •FAX 978.71O964
HOMEOWNER LICENSE EXEMPTION
Plow Fr1et
Date
Joe Locatka `7 2 /r 2 jz d� S
Home Owner Address T7
Home Owner Telephone
Preset Mailing Address
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units of lea and to allow such homeowners to engage an individual for
hire who does not poaaeae a licenser provided that the owner acts as supervisor.
DERNMON OF HOMEOWNER
Person(s) who owns a parcel of land on which ha/sbe resides or intends to resider on
which there is, or is intended to be6 a one or two family dwelling,attached or detached
structures accessory to such use and/or farm structures. A pawn who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"}wmeowner'shall submit to the Building OQlci4 on a form acceptable to the Building
OiIIciak that he/she be responsible for all such work performed under the Building
Permit
The undersigned "homeowner"asounes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations
The undersigned "homeowner"certifies that he/she undentands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements. .
HOMEOWNERS SIGNAMRE 'S I
APPROVAL OF 9UILDING INSPECTOR .
See other side for state code
�b CITY OF S.U-E.NI, :NLiSSACHUSETTS
BLLWLNG DEP.IRTNONT
110 W.1SHLNGTON STREET, 3iO FLOOR
Tom. (978) 745-9595
F.kX(978) 7�9844
ICIJ®ER2EY DRLSCOLL
MAYOR THo.+usST.Pmm
DIRECTOR OP PLBLIc PROPERTY/BL'ILDLYG COMMISSIONER
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 t l 1.5
Debris, and the provisions of MGL a 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 will be transported by:
(name of hauler) ((//
The debris will be disposed of in
(name of facdily)
(address of Facility)
5,
sfgnunue olpermit applicant
7
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