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17 HARDY ST - BUILDING INSPECTION (2) � 1 Cbnnnonwe:Jth of bl;usaclnnsclls $ 1� Board of Building Regulations and Standards CI IN OF 'r :. Massachusetts State Building Cute, 780 C NIR SALEM ( , Building Permit Application TO Construct, Repair, Renovate Or Denwlish a Unv-ur Tn n-f iunrlr Un ellin,e This Section For 011iciul Use only OuilJiny Permit Number: Dat , pplied. Iliilding 01176al(Print Mane) Signalurc Uu SECTION I:SITE INFO IATION I.1 Property Address: 1.2 Assessors.Hap& Parcel Numbers 17 F DA 5? I.la Is this an accepted street?yes no %lap Number 1'urccl Number 1.3 Zoning Information: 1.4 Property Dimensions: Znniny Dimricl Fn pos tjtlae Lai Anse(sq 11) Frontage(11) 1.5 Building Setbeclis IR) Front Yard Situ Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.I.e.40,554) 1.7 Flood Zone Informatlont Ld Sewage Dlsposai System: Militia❑ Private❑ Irma _ Outside Flood'Luna? Check if es❑ Munlciptd❑ On site Jispusul s)Stan ❑ 2.1 Pneri of Record: SECTION 3: PROPERTY OWNERSHIP' n/it{a GoMu(a r s µ sE O t`f V,une(Print),— C S feteaph.uLnIeP trc ay ct7. rig /Z75- k c-0v.- os f Enuil AJ � SECTION J: DESCRIPTION DF PROPOSED WORKS(check all that apply) New Construction❑ E.ristitsyBuildiny❑ FOwner-Occuplod CI Rein(s) ❑ Addition ❑Demolition ❑ Accessory Bldy.❑ r of Unts Other ❑ Speeily: BrierDescription Of Proposed \Vork-: Ne.i door ie de 6aioo ., g/ e f6 SECTION 4: ESTIMATED CONSTRUCTION COSTS Ilea Estimated Costs: I Labor and.\laterials) Official Use Only I. Building 5 I. Building Permit Fee: f Indicate how fee is determined: 2. Metrical 5 ❑Standard CiryTussn Application Fee I J. I'lumhiny S ❑Total Project Cost'I Ilea 6)x multiplier ?. Other fees: $ �— J. ,\Icch.ulical ill\ \('I i List: \Icchamic•II (Fire _ - --_—_-- �/ Cu I Iressionn s fol;tl .\II Fces: s _ - --- —_ .._ . n \mown:Pulu Project Cnsl: i ('heckAnuntrn:'� ©O ( r \o _ ❑ id in Full p UmstmJing 11.11,mce Due: 1 + sec TION S: c'ONS'I'RU("rION SERVI( F.S S.I Construction Suprrvisur Liccnsr(CSI.1 _ _..__ _ _. __ ---- _ I iauw Nuulhcr r+pira:iou I>;rtc Il+tl'SI. I1pcVechdual.-_.__..__—.._ _ _..._-- NIL .u1JSlrcal -..-._-- `—"- I lnrcslricteJllhliWiu'sli I') It R RatricteJlR�P.unil Dwcllin Cigi fawn.Shoe,LII' Rl' Rlwtin l'uwrin _ 'A s Window and sidin SF solid fuel Ilurning Appliances 1 Insulation Talc bona mail aJJress D D.ntolitiun 33 Registered flame Ingsruvemeni Contractor(HIC) Illy Rcglst P.vpiraliunDate 1 IIC l'ompan) Nmnc or I[IC Registrant Nanut Email addruss No.and Struct Ci Rown,State ZIP rele hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 157.1 35C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide 0 P permit. e building this afltdsvit well result in the denial of the Issuance or the g P Signed Affidavit Attached? Yes ..........C No••••••• ..•C SECTION 7s:OWNER AUTHORIZATION TO BE CODIPLETED 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. Data Print Ownur's Nutne(Mcwofc Signulure) SECTION 7b:OWNERt OR AUTtIORIZED AGENT DECLARATION By entering Iny a:ne below,I hereby attest under the pains and penalties Of perjury that all of the information calttafnrd in t ' p Ication is rate to the best of my knowledge and understanding. �3c /L 14int t)wnar's nr \ulhorired Agent's N.Inw Ililuctrunic Signaurtel Dalu VOTES: 1. .\n Owner who obtains a building permit to do his.her Own work.ur an owner who hires an unregisterrd contractor I nut registered in the Hume Improvement Contractor I HICI Program),will nu have access to the arbitration program or guaranty fund under M.G.L.c. IJ_tA. Other important information on the HIC Program can be found at w++w 11M, pw .•, I inrorntatiun on the Construction Supervisor License can be round at �!O 'III+ 2. \\hen substamial work is planned•provide the Informatl on bclovagt, finished bascm¢nt attics.Jocks kit porelu total flour area I sy. 11.1 - ---- — Ilabitable roust count Liruss hi,ing,lrcalsy. 11.l ..__.. —. . .. Noolherol'bedruoms \umberol'tircplaccs —_ Gunbcroflialfhalht \lallherofhathrounls \tuuhcroftle"s, pordlcs I\pc of Iwating sy da111 I I�nilt`+aJ ,.Open I\pc of�oollllg i\ilf lit :_ "I Id.II I'rllt�'at 11l ll;lre Ilxa.Igc Illa1 I`c+Ilb+lltiacd ft,r I oral ProiM l o+t" CITY OF S.ULENf PUBLIC PROPERTY DEPARTMENT u s�OeYfutl . Vwwe 1 b V%0WAG7 a IMAM• ULMM VAs1AO&SXM 010'0 Mt.9'a.745.1s" a VkL 07&No gay HOMEOWNER LICEAdS6 EXE.MMON Pies" Mat Date Job Locadara Home Owom Address l7 4rt-b Y sr Home Owner Telephone G t l • C7?" iZ7 f Present Ma ag Address The currant exemption of"Homeownsra"ware extended to include owner-occupied dwellings of two Units or teas mod to allow such homeowners to engage ao individual for hire who does not poeaen a license provided that the owner acts ae supwvi*w. DFYINMON Of HOMEOWNER Persons) who owns a passed of land as which hdshe residae or intends to resider on which there it, or is intended to be,a one or two &wily dwelling attached or detached jwxftm accessory to such use and/or farm stnactum A person who eomtnacts 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"assurnes responsibility for compliance with the State Building Code and other applicable by-laws and regulations. the undenigned "homeowner"certifies that he/she understands the City of Salem Building DePsment minimum inspection procedures and requirements and that he/she "will comply with said procedures and r aqu' ants, HOMEOWNERS S1GNAIT,'RB APPROVAL OF SUILDIVG NSPECTOR See other side far state code CITY OF S'kL&N(, AUS.,CHL,'SETTS JULONG DEP.1RTtE`T 120 WASHNGTON STABJiT', 1iO FLOOR 11t. 1973) 743.9595 FAX(973) 740-984 K)1®FJlL6Y DRLSCOLL MAYOR htoxw ST.PMUA Otucrot ov PLsuc PllaveltTY/et:mD0fa coxaIISSIONEA Construction Debris Disposal Affidavit (required for all demolition and renovation work) rn accordance with the sixth edition of the State Building Code, 730 CMR section 111.J Debris, and the provisions of MCL a 40, S 34; Building Permit M is issued with the condition that the debris resulting from It1 work shall be I I1, 3 I JOA. disposed Orin a property licemed waste disposal facility as deRncd by NICL c I The debris will be transported by: S� v p (A Q J (n.+me ur'haular) The debris will be disposed of in : (name offjfumlily) LLLLL f�ddrni of f��diy) it a o ,, it �pp6anr s 3a �z J� a