12 HARTFORD ST - BUILDING INSPECTION (7) /f} 1 The Commonwealth of Massachusetts
Vv i Board of Building Regulations and Standards CITSALE
OF
I Massachusetts State Building Code, 730 CMR Revised LVbla 201!
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family avelling
This Sectt'oRF6rOff1cial sa0n
Build_in it Number: Voite pli t
Building Official(Print Ntfine) $lgnat a, pnt`
SECTION 1:SITE INFORkdoR
l erty Address: 1.2 Assessors Map&Parcel Numbers
ifs dGo^>< �i '�
I.la Is this an accepted street?yes l/ir Map Number Parcel Number
1.3 Zoning information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
p► Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided '
1.6 Water Supply: (M.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
❑'Public❑ Private Zone: _ Outside Flood Zana7 Municipal O On site disposal systdC3
Check if yesC3
SECTION Z:; PROP.ERTY'OV1VNERSHIPL77
2.44 O er of Record:
�.�nn� Ge . alase!/o 54 (�wr // Q 1 7977
' t) City,staeZI
1622 547W-, F
7
Tepol
No-and Street
Email Address
SECTION 1 DESCRIPTION OF.PROPOSED.WORJO'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ At eration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ trofUnits Other ❑ Specify:
Brief Description of Proposed Work": rL-- V10 57�1-5-
p r7c —C,�S �c✓ in tir✓vl6:f'�vcr�>
SECTIOtN 4: ESTINLATED CONSTRUCTION COSTS-
item Estimated Costs: OffIclal Use Only...
Labor and Materials
I. Building S L Building Permit Fee:S' Indicate kow fee is determined:
2. riectrical S CIStandard._City/TownApplicationFes.`
❑'fatal PiojectCost(Item6)xmultiplier X
3. Plumbing S ?. Other Fees S
1. ,Mechanical (IIVAQ S List: -
i. Mechanical (Piro
SiiP tression) lbtal :\Il Fees:.S
/ Check No. Cheek rlmuuut: C:uh :\nwunC
n 1'11ta1 Prniect t'u,t: S
f ❑ Paid in Pall ❑Outstanding Ilalallec 01ie:
sEC'rloN 5: co:Vs'rKUCTION SERVICES
5.1 Construction Supervisor Liccuse(CSI,)
License Number Expiration Date
Name of CSL I[older List CSL'rype(.see below)
Type Description
No. and Street U Unrestricted Buildings up to 35,000 cu. it.)
R Restricted 1&2 Famil DwOlin
city/rown,State,ZIP RI Ru so
RC Rootin Coverin
WS - Window and Siding
SF Solid Fuel Burning Appliances
[ Insulation
D Demolition
1'cle hung Email addrcse
5.2 Registered Home Improvement Contractor(II IC)
HIC Registration Number Expiration Date
I IIC Company Name or IIIC Registrant Name
Email address
No.and Street
Ci /Town State ZIP Tale hone
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 .........O
SECTION7a: OWNER AUTHORIZATIONTOBECI SalLETEDWHEN
OWNER'S AGENT OR CONTRACTOR, PLIES FOR BUILDING PERMIT
I, as Owner of the subject property,hereby authorize
to ac n my behalf, in all mutters relative to work authorized by this building permit application.
Date
Print Owner's Name(Electronic Signature)
SECTION 7h: OWNER' OR AUTHORIZED AGENT DECLARATION
;con
y ent ng my name below, I hereby attest under the pains and penalties of perjury that all of the information
tried in this application is true and accurate to the best of my knowledge and understanding.
711 /
l'rin Ownar's or Authorised:\�ent's N.une(Glectruntc Jignanre) --
Date
NOTES:
I. :\n Owner who obtiins 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
u ww m;ts+.teuvhrca Information on the Construction Supervisor I.iccnse can be found at www mass.-a,v dLU
3. When substantial work is planned,provide the information below:
rota) floor area(;q. It.) ___ _(including garage, finished basement/attics,decks or porch)
Gros; living;rca 0+ ft.) _ Habitable room count _
Nnwbernftirrplaces_.--_----- Number ofbcdroorrts -----.------_.-_--_--
Number of b•uhroout.; -_-- Nuntl±aroFhalf batlu __ -- —_-.—---.
I",Ile ofh;,tling ;ySiant Nuntberofdack,,'In±retes .._.. ---,- --__--
- ---
Eucl tsci u pen
I "I,u.d I'nq:rr �'Ju 11'0I t.ra" MAV he ;ilh,litnl:d r;,[ I'tl jiAt['oat . - _ -
CITY OF S.U.E.Nf
PUBLIC PROPERTY
DEPART- ENT
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rtL rsrsssses •v..s r.srad�ats
HOMEOWNER LICLNSS EXE.I4PTIO,V
Plow "I
Date -7 4 <L L /—
lob Location GL fs-4,-- � :�,L� /W,61- O,-%
Home Owner Address Z &
Home Owosr Telephone 7 --D
Present Mailing Address A
dL�7c'i
no current exemption of"Homeowners"was extended to imlude owner-occupied
dwellings of we Units or few and to allow such homeowners to engage an individual for
hit*who does not possess a ticenso provided that the owner acts as s>uperviaor.
DEFINITION Or HOMEOWNER
Person(s) who owns a psreal of laid on which hdshs resides or intends to reside, on
which thaw is, or is intended to bq a one or two rmWIy dwelling, attached or detached
structures seaessory to such use and/or rum structures. A pawn who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building OQkiai,on a form aeceptabla to the Building
Offleial, that helshe be responsible for all such wort performed under the Building
Permit
The undersipied "homeowner"assumtes responsibility for compliance with the State
Building Code and other applicable bylaws and regulations.
The undersigned "}nomeownce certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that hdshe
Will comply with said procedures and requirements.
HO.,tEOWXERS SIGNATLRB
APPROVAL OF 91VILDING NSPECTOR V�pn
See other side far state coda
S �
0 \
CITY OF S,6UZNf, LUL S&wi-iusETTS
)� O RTJ
t:MDW(;OEP.1MNT� 1 137-It.VGTOY S T�&T, 3 Pt.00t
t ~ - L (978) 145-9595
KI.%(0M-EY 0R(SCOLL PAX(978) 7.10-934,6
,bUYOR T1lo.%t .9 ST.FIER"
DIaSCTOR OF P(:Ot.1C PROpERTy/BCILDL�IG COSU(f55tO.YER
Construction Debris Disposal At'f7davit
(required for all demolition and runovetion work)
in accordance with tlta sixth edition of the State Building Coda, 730 C�bfR Se L
Debris, and the provisions of lb(GL a 40, 3 54; ction ! l S
Building permit M is issued with the condition that the debris resulting from
this wurk shall be disposed of in a properly licensed waste disposal 111, S 150A. facility as defined by lti(GL c
1'he debris Will be transported by:
O
(n�ma ufhaulur)
The debris will be disposed Orin :
(name at 11cdrty) —
-----(l -1C5 offl,il—It/)
i�Snatn urpcnnit dpplicanr