7 HARTFORD ST - BUILDING INSPECTION (2) 1
The Commonwealth of Massachusetts
f Board of Building Regulations and Standards CITY
Massachusetts Slate Building Code, 780 CMR, 7°edition OF SALEM
�� Revised Jarnngv
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. :oav
One-or Two-Family Dwelling
This S 'on For Official Use Only
Building Permit N ber: Datg4p Iied:1
Signature: •L I !� Y / 0
Building Commission nspeclor of B ' in r v Dale
SECTION 1c SI E INFORMATION
x 1.1 Pso erty d ers 1.2 Assessors Map& Parcel Number
L l a Is this an accepted no Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq n) frontage(tt)
1.5 Building Setbacks(R)
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:
Zone: _ Outside Flood Zon1
Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Name(Print) Address for Service:
1
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKr(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition O
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief scriptio of Pro sed ork':
�w
SECTION 4: ESTIMATED CONSTRV ION COSTS
Item Estimated Costs: Official Use Only
Labor�anqd Materials
I. Building S OU d(3 1. Building Permit Fee:S Indicate how fee is determined:
O Standard City/Town Application Fee
2. Electrical S J106 ❑Total Project Cost(Item 6)x multiplier x
3. Plumbing I $ d 2. Other Fees: S
4. Mechanical (HVAC) S 014 List:
5. Mechanical (Fire S ^/9
Suppression) Total All Fees:S
Xj J y�oo Check No. Check Amount: Cash Amount:
b. Total Project Cost: S ❑Paid in Full ❑Outstanding Balance Due:
q�
1 �
J
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) /:f ��">'CY Ci Je hb `
)/ � I.iccnse Number L_ Iitplma'o.nn Uatt
Nam
e of CSI.• Iu1Jer I.ist C'SL Type(see v below)
4
-r-pe Description
:WJrcs U llnresirictcd u to 35,000 Cu.Ft.
R Restricted IB2 FamilyDwellin
Signature M I Masonry Only
Z 2 7 RC Residential Roofing Covering
X Ilephline WS Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Inslallallun
D I Residential Demolition
3.2� It red He a I�tpp�ryfv�emq Gotncror(HIC) J7/C,/ '�
Br =( Regis ration N tuber
I IIC Comp Name or tilt:Regtst amC C �/ -y�!
AJJ �A �a�r7✓ /rL P �b
,X Es imuon Date
Si u Telephone
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...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED 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
X relative to by this building permit application.
Si tore of ty
r Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the spementts and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print N e
Si rc o r or Authorized Agent. Date
(Siuncd under the pains and penalties of 'u
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 W have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115,respectively.
? When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished bastment/attics,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"
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.hip aired have no anployas Them su4eorwmmn hove !L Q Fun elieiaa
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I No work@'conF insurance J. ❑ We an a cerpwatlaa and in 10.�nEGenical repein err err dew
r qukv4Ll orlkan hew etswolwd thole
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mynif (NA workers'comp. C. I JZ 1(1).ad we hm no 12.0 Roof repaim
insurancerequinalt cmp' 3 lN*warkew I1.0odaw
comp`insurateeotegaire l
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Insurance Company Namo:
Policy a or Saltine.Lie.V. Eapirmioe Dow. '.
fob lire Addicts: Ciry/InaVZipe
.\stub s copy of tbs workerrs'compomadee patley dwb"lko pop(showing the pellep tmmbr sod sepiratlsa deem
Failure to swum coverage a requited under leclioe 2JA of MOL IL 152 cats lead to the impooWm of criminal penalties are
fine up to 11.300.00 and/w one-year imprisoentamt-W waY as dvd penalties is tlra farm of a STOP WORK ORDER anal a Her
Of up to 52J0.00 a Jay iWinss the violator. IM 3@M.*W that a wpy of this statement maybe rwwarded to the Onfn or
incc.0 adiu+ta of Jte nlA for insurance covenips v%witicatialt
herelll cc major/ pyti I prneld"v//er/aq their tAs infMMfIN providsll!u ,Of it 1760 rwI a wtehl
: • r'j Uaec 0
n/J/cid u+e anIA Os not weite uo this errq to!i a vtnpiotd by ciy err tow n//h iad
Ciry or town: errtniWActaeel__
I�ouent.\uthonty lcircle nne►:
I Ituard of IleaUk 1. RudJleq 1)cparemunl ). city/rows clerk A. fleclricsi Gnpeclor 1. Ptunrbtae impeclar
6. thher . _
i L...itace Pcnon: _ _ Phone a.
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
P111 11 IJC .,MS(aarT e).\II\I, fit.\NNIII .11.•�1'� '
\t '1"� f11:'�'1-%1.4•/yN �l°\X:'/76i1J'/11M
construction Debris
ork)VIA
-quiredrur jl moltion jml ronovaiun w
In accordafx:e with the simtll edition of the State Building Code, 730 CMR section I
visions of MGL a 30, 54;
Debris, and the pro MGL o
is
issued with the condition that the debris resulting floor
Building Permit M - 1 licenaud waste disposal facility as defined by
,his work shall he disposed of in a proper Y
111. 9150A.
The debris will be transported by:
(its ul' uler)
-I-he debris will be disposed of in
(n title of a.l Ity
I:I,td/ela of 1'aalily►
.lsnature./manfil.&PPlikant
.late