12 HARTFORD ST - BUILDING INSPECTION (5) The Commonwealth of Massachusetts CITY
Board of Building Regulations and Standards OFSALEM
Massachusetts State Building Code,780 CMR,70'edition Revised January
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, 2008
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Num er: Date am Applied:
Si.-nature:
ue: �'u''` !�^ 7/ 6)//
Building Commissioner/Inspector of Buildings Date r
SECTION 1:SITE INFORMATION
1.1 Pro a Adana"ss• ' 1.2 Assessors Map&Parcel Numbers
l� wr+fwd SI 09- 01rll -O
1.to Is this an accepted street?Yes_ no Map Number Parcel Number
1.3RZ ng Information:Jut / %Iy 1.4 rty Dimensions: 70
Zoning District Proposed Use rfrM Lot Area(sq It) Frontage(It)
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:
Public Private❑ Zane: — iOut ide Flood Zona.' Municipal 0 On site disposal system ❑
Chock if y:s❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownert of Record: 1?- #6'4 94 0
Mcr.,.Y Sc�tirrtl
Nzunc run! Adds: s fur Service:
(ti/�oe-
91'01u 11� Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction Cl Existing Building iQ Owner-Occupied R Repairs(s) ❑ 1 Alteration(s) ❑ 1 .Addition
Demolition ❑ Accessory Blds.❑ Number of Units__i _ Other ❑ Specify:
Brief Description of Proposed Work'-. '91d daiptr" r✓ ' A-
d_/e /r`� n� ---- — ------- -- ----
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: • Official Use Only
(Labor and Materials)
1. Building $ 2-S-0 1, Buildins Permit Fee: $ Indicate how fee is detemtined:
2.Electrical
❑Standard Cityi Town Application Fee
$ Z
❑Total Project Cost'(Item 67 a multiplier x
3.Plumbing 2. Other Fees:
4. Mechanical (I-IVAC) $ List:____----------_---------------_- _-___--
5.Mechanical (Fire $
Suppression) Total All F.es: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ Z SO ❑Paid in Full ❑Outstanding Balance Due:
I
SECTION 5: CONSTRUCTION SERVICES tiw
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL Holder List CSL Ty
pe(see below)
Address Type Description
U Unrestricted(up to 35.000 Cu.Ft.)
R Restricted 1&2 Family Dwelling
Signature - M Masonry Only
RC Residential Roofing Covering -
Telephone ws Residential Window and Siding
SF Residential Solid Fuel Burning Appliance:Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.g 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 79: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
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
1, (/diGr^ ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf
P J,4✓`JUe
Print Name IC. V 7 (�
Signanree of Qrvmd or'Authorized Agent Date
(Signed under the 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 an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will Ut have access to the arbitration
program or guaranty fund under M.G.L.c, 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I0.R6 and I I0.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"
CITY OF S.UI F-Nt
PUBLIC PROPERTY
DEPARTMENT
[1fO�Y�n�r•.r.
wra. i b vmwceoN snasr�s�ura wa�oRQrn of f'0
raL t-&7+6•9s"•V.%x rs.74p9Ne
HOMEOWNER LICLNSE EXEMPTION
Phew inlet
Dats
Job Location
Home Owner Address S
Home Owner Telephone 8 6oTs - 7 3 6 fs
Pmeom Mai&S Addreae /2
The current exemption of"Homeowners"was extended to include ownw-occupied
dwellings of two Units or lean and to allow such homeowners to engage an individual for
hire who does not possess a license,provided that the owner acts as supervisor.
DERNMON OF H0hWWNER
Person(s)who owns a pared of land on which he/she resides or intends to resider on
which there is, or is intended to ba,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
ourneowner"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"horneowner"assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner"certiAa that he/she understands the City of Salem
Building Department minimum impaction procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE �Cr
APPROVAL OF BUILDING CISPECTOR
See other side for state code
CITY OF S.U.E.NI, lL1SS.kCHUSETrS
• BULDLNG DEPARTMENT
' 130 WASHNGTON STREET, 3' Rom
TtrL (978) 74S-9595
FAx(978) 740-9846
KISIgF t RY DRISCOII.
T
,�1AYOA ftO.+t:�s ST.PtF.RRs
DIRECTOR OF KBLIC PROPEATY/Bt.MDLNG COMMISSIONER
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 l 11.5
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
111, S 150A.
The debris will be transported by:
l-
ec>o- Guy - J "qk /
(name of hauler)
The debris will be disposed of in :
(name of facility)
(address of facility)
`gnature of permit applicant
date
.Icbnvird.w