44 HANSON ST - BUILDING INSPECTION �'2S 00 C_K ` 8
The Commonwealth of Massachusetts iHsPEE'�'►ONA Ylff
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Board of Building Regulations and Standards' SALEM
Massachusetts State Building Code,780 CMR
1RA _b nevi rar r zorr
Building Permit Application To Construct,Repair,Renovate O o ish a
` One-or Two-Family Dwelling
This Section For Official'Use Only
Building Permit Number: Date • piled:
��1 l
1Y 1 Buil$ing Official Mmt Name) -.Signature e .
I�1� SECTION`1.SITE INI ORMATION '
1.1 P perty Address: 4/y / n JV^ S-¢ 1.2Assessors Map&Parcel Numbers
a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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 if yes❑
SECTION i-PROPE tTYOWNERSHIP'
2.1 caner'of Record:C �� ` /1((� / S-
Jl�t� pa /�r%V�-l� &�r % /7�//�lyn -
1 J / �G
ame(Print) City,State,ZIP
'lada�«r.�.f/Q�c.��/c
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction fQ' Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work :
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate.how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee -
❑Total Project Costs(Item 6)x multiplier x -
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
ression
/ Cheek No. Check Amount: Cash Amount:
6.T al Project Cost: $ 16C)0. 00 ❑Paid in Full 0 Outstanding Balance Due:
SECTIONS. CONSTRUCTION SERVICES
5.1 Construction Supervisor L'icense(CSL)
, I t• License Number Expiration Date
Name of CSI;Holder V"' H!4 uv !
List CSL Type(see below)
No.and Street Type Desenption.
U I Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted I&2 Family Dwelling
City/Town,State,ZIP M Mas
RC Roofing Coverin
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State,ZIP Telephone
SECTION 6:WORKERS,COMPENSATION INSURANCE AFFHIAVIT(NLGJ c.152.§250(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 DE COMPLETEA WHEN
OWNER'S AGENT OR CONTRACTOR APPLLE.S FOR HUMPING 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 Name(Electronic Signature) Date
SECTION 9b: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
contained in this application is true and/�c rate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Ndmc(Electronic Signature) Date
'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
x�ovoca Information on the Construction Supervisor License can be found at jnyAjj ss.>ovc /das
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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 heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
`�, QTY OF SALEM, MASSACMETTS
5 r BUILDING DEPARTMENT
"' 120 WASFENGTON STREET,3RO FLOOR
i. TEL. (978)745-9595
F
KIMBERLEYDRISCOLL FAX(978)740-9846
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date / \
Job Location .rl��C/ lYCy r�Jo — sa(cc•, /�k4 t� /57`7'a
Home Owner Address 11/r-/ /{14rLl„ f l JL6_1. /y/1�1 O/!`7o
Present Mailing Address L/CK lYG Lrlr� f-/ 1G l s�. /W/t 0/Sp0
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
Persons)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 SIGNATURE
APPROVAL OF BUILDING INSPECTOR
CITY OF SALES MASSA(HUSE M
BI mvmDEPAjmznr
120 WAWGXKSnWO3ADFiooa
UL IM)745-9595.
FA1r(M- )740.98"
SIMBERIBYDRISCbLL
MAYOR TrBou"STYMM
DnWC Cut CFPUBUCMOFWT/BUMD1WaMOAS90NER
Construction Debris Disposa/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 c40,S 54; Building Permit# is issued with the
condition that the debris resulting from this work shall be disposed of in a property licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
T� Ar"r
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
�,✓�
5 rknature of applicant
Date
-0260/
15-0249.j 15-0259
232
15-0258
15-0250
15-0365 !
-45-0257
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15-0259\.
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j1 IIJ
i - 15-0255
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15-0385
15-0254
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