9 HARTFORD ST - BUILDING INSPECTION c� The Commonwealth of Massachusetts
Board of Building Regulations and Stant�d oEll RVICES CITY OF
j Massachusetts State Building Col-@51�121L E Revi edMaSALEr42011
Building Permit Application To Construct,Repair,Renovate Or Devi Q
One-or Two-Family Dwells a� 2
This Section For Official Use Only
Building Permit Number: Date Appli
Budding Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Proppg�rty A#�ddress: 1.2 Assessors Map.&Parcel Numbers
L11 Q HRr+ oro S{res&
Lla Is this an accepted street?yes ✓ no Map Number Parcel Number
^ 1.3 Zoning Information: 1.4 Property Dimensions:
(V�1 Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1—' 01.6Water
ding Setbacks(ft)
Front Yard Side Yards Rear Yard
red Provided Required Provided Required Provided
Supply:(M.G.Lc.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Private❑ Zone: _ Outside Flood Zone?Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP' '
2.} /Owner'of Record:
cps fire V'W 2v4r� 54-P t1 n A- O 17-2 o
Name(Print) City,State,ZIP
� f�-�1rt�om Cd-eee� �i'I�'+^lYti-l�Cal�--
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORV(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Descriptigit of Proposed World:
If'7'� c t Q.t S i�U
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials y
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard CityfFown Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ h—h
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 3 .O'N3,cA 11 Paid in Full 0 Outstanding Balance Due:
t i
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type - Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City(rown,State,ZIP M Masonry
RC Roofing Covering
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 AFFIDAVIT(M.G.L.c.152.§ 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...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING 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 7tr:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of pedury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
(Lr ) (-X S- Z( -( �
iri�t er's or Authorized Agent's Name(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
wvvw.masssov%oca Information on the Construction Supervisor License can be found at wtnv.mass.>ot, v;dns
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/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"
e-
i
CITY OF SALEM, MASSAaius s
BUILDING DEPARTMENT
120 WASHNGTON STREET,Yo FLOOR
7tL(978)745-9595
KA BERLEYDRISMLL FAX(978)740-9846
MAYOR THcmAs STYIERRE
DIRECTOR OF PUBLICPROPERTY/BMDING 00MMISSIOMR
Construction Debris Disposal 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 properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
Tbr\ halo
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Sign ture of applicant
Date
F `
CITY OF SALEM, MASSACHUSETTS
BUILDING DEPARTMENT
�T '... ` •(EMI
120 WASHINGTON STREET,3"D FLOOR
n usn TEL. (978)745-9595
FAX(978)740-9846
KIN BERLEY DRISCOLL
MAYOR THOMA3 STTIERRE
DIRECTOROF PUBLIC PROPERTY/BUILDING CONMSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date
Job Location W Vi(7 tv(17Ke
Home Owner AddressS}�etl—
Present Mailing Address � —
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 SIGNATURE
APPROVAL OF BUILDING INSPECTOR