15 HARRISON AVE - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards Ft)It
;
- r MI'Nlt m.�l.rrY ry' }� Ma55aChaSCUS State Building Code. 7SO C'MR. 7"' edition
I'SI{
Building Permit Application To Construct, Repair. Renovate Or Demolish a Rci iy ,/hmaw i
Onto- of Tit o-Frunilr D.rrllin,t; 100E
This Section For Official Use_Only
p\ Building Permit Number. Date Applied
signawre:
Building Commissioned Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Propert Address: v� 1.2 Assessors Map & Parcel Numbers
1S tt191zti Ss"1
I.la Is this an accepted street? yeses _ no_ Map N'unther P❑real Numher
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning L'istrict Proposed Use Lot Area(sq 8) --_ Frontage (li)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
! Required Provided Required Provided Required Pnry idcd
i
1.6 Water Supply: (M.G.L c. 40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone'' Municipal ❑ On site disposal s stem ❑
Public L Private❑ Check if yes❑ P I y'
SECTION 2: PROPERTY OWNERSHIP[
- ��iSa Pz Gel I — 15 �)916 QW gun s�/e
_ "" rv��o
Name(Print) Address for Service.
�, /�
f amrc Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ [Accessory
Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ElAddi(ion ❑
Demolition Bldg. ❑ Number of Units_ Other Specify:
Brief Description of Propos d Work': --
� a ►�a;� va,rc� I
SECTION 4: ESTIMATED CONSTRUCTION COSTS
1(zm Estimated Costs: Official Use Only
(Labor and Materials)
'. Building 'S 1. Building Permit Fee: $ Indicate how fee is detetouned: j
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost' (Item 6) x multiplier x
3. Plumbing 5 2. Other Fees: $
4. Mechanical (HVAC) .S List: —
5. Mechanical (Fire
Suppression) Tnsd All Fees: S 2�
Check No. Cheek Amount: Cash Anunu,tI/i�—
6. Total Project Cost: $ Paid in Full 0 Outstanding Balance Due:____
SECTION 5: CONSTRUCTION SERVICES j
5.1 Licensed Construction Supervisor (CSL)
License R'umhcr [cpi r;uion Date
Nana of CSL- Holder
List CS1. Type(see heluM
1'v c Descri riiun__
\ddress
C Unrestricted J(�t) to 35.000 Cu. H.)
-- R Rc,n i,led 1l\'_ Family Dwelling
Signature y1 %lasonry Only
RC Residemiul Roollne Cu\rnn�
fCICph UOC \\5 I<e>il1CIIIIaI %v IIItIU\1'alld Siahno _
SF Residenti;d Solid Fuel Burnam_ \pphancr hisl.t1l.w,41
D Rcsidenual Demo mon
5.2 Registered Home Improvement Contractor(IIIC)
HIC Company Name or HIC Registrant Name Registration
Address ----
Espirutic:i Date
Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M_G.L. c. 152. § 2506)) --�
Workers Compensation Insurance affidavit must be completed and submitted with this application. F:,i!arc �o piokile j
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached'. Yes ....... JI
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
I OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
authorize— — _ _ to act on my behalf, in all matter:
reiat.ve to work autholu�ed by this building permit application. - l
' I
Sienauire of Owner Dale -------- —_. -- -- -1
SECTION 7b: OWNER' OR AUTHORIZED AGENT DEC1,ARATION
I
L --- . as Owner or Authorized A,e,-•: l;ereby declare
that the stnieiz,ents and information on the foregoing application are true and accurate, to the best.of.-ry knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Siened under t_lie pains and penalties of perjury)
NOTES:
1. An Owner who obtains a building permit to do his/her own work, or an owner who hires all unregistered contractor
(nut 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 Prucram and
Construction Supervisor Licensing (CSL)can be found in 730 CMR Regulations I IO.R6 and I I O.RS. respectively.
2. When substantial work is planned, provide the information below:
Total flours area(Sq. Ft.) _ (including garage, finished basement/attics, decks or punch)
Gross living area iSq. Ft.) _ Habitable room count _
Number of fireplaces Number of bedrooms
l Number of hathr ores Numbei of halt/haths
l fype rf heating system Number Of deekS/ ponchcs
.fype of cooling system [nc lowed _ Upen
3. "Toad Project Square Footage- may be substituted for "Total Project Cost"
CITY OF S.3L .M
PUBLIC PROPERTY
DEPARTMENT
.MAVM 130 WASHINGWM SINEW•SAI EM NUSIA0 LSETTS 01970
lti 978-74S.9S95• Fwx:979-740-994
HOMEOWNER LICENSE EXE.MMON
Please Print
Date 6—21 — 0 Sr
Job Location /X A-1,q R R/ s6 N AGLO-
Home Owner Address /
Home Owner Telephone — -5 �
Present Mailing Address S R M Lo
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 who.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 hdshe be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner"assumes responsibility for compliance with the State r
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner" certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING LYSPECTOR
See other side for state code
{ CITY OF SALEM
Y }
PUBLIC PROPRERTY
DEPARTMENT
\I r. I_K A Nil H Ni,.ON Snow ♦ S.0 rv, \Lt;i.0
Construction Debris Disposal Affidavit
(retluiied fior all dcnwlition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CIv1R 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
t 11. S 150A.
The debris will be transported by:
�f r( G Z 171 s PISa�
(name of haul r)
I he debris will be disposed of in
(name of facility)
(addrets of facility)
signature of permit applicant
date