24 HANSON ST - BUILDING INSPECTION (6) t
The Commonwealth of Massachusetts
_� Board of Building Regulations and Standards CITY OF
>< 0l Massachusetts State Building Code, 780 CMR SALEM
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised:L/ar 2011
One-or Two-Family Dwelling
\1 Building Permit Number: This Section For Official Use Only.
Date Applied:
BuilJing Official(Print Name). —� 1 r— - �z � �`3
. Signature - Date
SECTION 1:SITE INFORMATION
LI P opertyAddress:
y HQ.1 C 2 n 7- 1.2 Assessors map&Parcel Numbers
1.la Is this an accepted street?yes no Nlap Number
_ Parcel Number
1.3 Toning Information: Ld Property Dimensions:
Zoning District Proposed Ua�—
Lot Area(sy It) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards
Required Rear Yard
y Provide) Required Provided
Required Provided
1.6 Water Supply:(M.O.L c.40,§54) 1.7 Flood Zone Information:
Public❑ Private❑
Zone: _ Outside Flood Zone? l.8 Sewage Disposal System:
Check ifyes❑ Municipal❑ On site disposal system ❑
2.1 Owner'of Record: SECTION 2- PROPERTY OWNERSHIP'
1 roti ✓ti Sal e A�N�Sme(Pont) A '
City,State,ZIP
ay hG nor .
:mJ Street 791 65 y-777�
Nu.
Telephone 'mail Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) 6- Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units
BrieFDescriptionofProposedlYork': Other ❑ Specify:
N c� ne fS
dP 1� yn
----_
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Offlcial Use Only
I. Building S 1. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
3. Plumbing S ❑Total Project Cost'(Item 6)x multiplier x
?. Other Fees: $ �.
d. Nlcchanic:d (UVAC) $ List:
5. Nlachnnical (Fire
Su ression) S Total All Fees:S
Total Project Cost: S ZSIdt70 Check No._Check Amount:
Cash Amount:_
❑Paid in .,—Check,
l ❑Outstanding Balance Due:
I
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
----- Ex iration Date
License Number P
i
Name of CSL Holder List CSL Type(see below)�—
Type l : Description
No.and Street U Unrestricted Buildin s u to 35,000 cu. ItJ
R Restricted 1&2 Family Dwellia
IvI Mason
Citylrown,State,71P RC Roofin Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
onon
--- --- Email address D Demolition
'role he
5.2 Registered Home Improvement Contractor(HIC) fIIC Regis r Expiration Date
HIC Company Name or HIC Registrant Name
Email address
No.mid Street —_
'rele hone -
Cit /Town,State,ZIP
SECTION 6:WORKERS,.COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. I52.§ 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 p
Signed Affidavit Attached? Yes ..........❑
No.......... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED W HEN:
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING 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.
Date
Print Owner's Name(Electronic Signature)
SECTION 7b:OWNER'
OR AUTHORIZED AGENT DECLARATION
13y entering my name below,I 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. . Zb /3
Date
Print Owner's or Authortced Agun's Nume(L•Iectrunic Signature
NOTES:
1 QrotOregistered inbl et Home I aprovementtCmomctotr(HIC)Progrnm)ns ill nafshave access tottregistered the arbitration tractor
p`is�a�nti;.�ooca lnforntnt on on the Constru tioOn Supervisor Li ease can be found atC P�1Srmmcay—b IPf_ound at
2, When substantial work is planned,provide the into(°ncludinglgarage,finished basement/attics,decks or porch)
'rota) floor area(sq. ftJ Habitable room count
Gross living area(sq. ft.)_____._.—_.-- Number of bedrooms
Number of fireplaces Number of half/baths
Number of bathrooms ,lumber of decks/porches rype of of heating system — Enclosed Open
Type of cooling system
} Total Project Square Footage"may be substituted fur"Total Project Cost"
CITY OF SALEM, NWSACT IUSETTS
fit BUILDING DEPARTMENT
s .trc 120 WASHNGTON STREET 3�FLOOR
TEL. (978) 745-9595
FAx(978) 740-9846
KIMBERLEY DRISCOLL
MAYOR THOMAS STYIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date /Z-o— 2o/-3
Job Location ! o��l (7c�✓I SUn !fj Stiles
Home Owner Address r 2 5 "r�elNy
Present Mailing Address ZY flg 5" T C� le l"4
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 SIG NATURE
APPROVAL OF BUILDING INSPECTOR
7
CITY OF S.CUE.Nm NLkSSACHUSETrS
'' BI;IMNG DEPARTMENT
120 W.aSHNGTON STREET, 3w FLOOR
T EL (978) 745-9595
KIJiBERLEY DRISCOLL Rux(978) 740-9846
.bL-XYOA TFIOSLis ST.PtERRB
DIRECTOR OF PUBLIC PROPERTY/BCILDL G,CONNISSIONER
Construction Debris Disposal A fidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section t t 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit it 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 biGL c
1 11, S 150A.
The debris will be transported by:
y
y /lSer�' arr�°dsa /
(name of hauler)
The debris will be disposed of in
(name of facility)
_-----_(address of facility)
signature ofpermit applicant
(laic