12 HARTFORD ST - BUILDING INSPECTION (9) The Commonwealth of Massachusetts
F
Board ofBuilding Regulations 80 S R, 71ds CITY
Massachusrus State Building Ctie, 780 C'MR, 7"edition OFSALEM
dJamui RrvisrdJunaun•y Iuilding Permit Application To Construct, Repair, Rrnorate()r Demolish a /. :IHAY
One-or Two-Family Dwelling
This Section For O.fft ' se Only
Building Permit Number: ./ Date App
Signature:
Building Commissioned Inspector of Buildings e
SECTION 1:SITE ORMATION
pWaterSupply:
ss: 1.2 Assessors Map& Parcel Numbers
is an acce ted street?yes no Map Number Parcel Number
ing loformatbo: 1.4 Property Dlmensloos:
istrict Proposed Use Lot Area(sq 11) Frontage(11)
ing Setbacks(11)
Front Yard Side Yards Rear Yard
d Provided Required Proided Required Provided
r Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?
Private❑ Check if es0 Municipal❑ On site disposal system O
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownerr of Record:
/ xt6 .T�dF.2 x /2 &, 4.-,/ ST.
y Nome) Address for Service:
Iv �% �/r7e/)l�tF- 736�
SignWure Telephofic
1 SECTION 3: DESCRIPTION OF PROPOSED WORKS(check oil that apply)
New Construction O Existing Building O 1 Owner-Occupied O I Repairs(s) ❑ Alteration(s) ❑ Addition O
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other O Specify:
Brief Description of Proposed Work': :ems, e
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Ofllelal Use Only
Labor and Materials
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
O Standard City/Town Application Fee
2. Electrical S O Total Project Cost)(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (FIVAC) $ List
5. Mechanical (Fire S
Su ression Total All Fees:S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S i
0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
I.iceme Number li.xpinlion Date
Namc of CSI.- I IuWer List CSL Type(see below)
rs or Description
Address U unrestricted u to 35.000 Cu.Ft.)
R Restricted Idt2 Family D%ellin
Signature M M• Only
RC Residential Roulin C'overin
I'elephone WS Residential Window and Sidin
SF Residential Sulid Fuel Bumin A liance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or IIIC Registrant Name Registration Number
Address Expiration Date
Signature Tclepbune
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.f 2SC(6))
Workers Compensation Insurance affidavit must be.complcted and submined with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes..........O No...........O
SECTION 7s: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: OWNEW OR AUTHORIZED AGENT DECLARATION
1 ( ,e9 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
beha .
XPrim � . fir/
Authorized Agent Date
under the im and penalties of 'u
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who him an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program), will Rg 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 I IO.R6 and 1 IO.RS,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 healing system Number of decks/porches
Type of cooling system - Enclosed Open
3. "Total Project Square Footage"may be substituted fur"Total Project Cost"
CITY OF SM-E.M
PUBLIC PROPERTY
DEPARTMENT
r
.%"VM 130WUMMOMMSTUM•Suty VAsuoa'scrn019'e
rEL 976-7454S"• F%z.978.74O9W
HOMEOWNER LICENSE EXEMPTION
PIN" Prime
Date io /
Job Location �o� /"/ ,;' o/ V7--
Home Owns Address c' cT e,c
Home Owner Telephone D 0,0v- 7 a6d
Present Mailing Address 11.s2 e
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or less and to allow such homeowner to engage an individual for
hire who.does not possess a license,provided that the owner acts as supervisor.
DEFINMON 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 dwellin& attached or detached.
structures accessory to such use and/or farm structures. A person who constructs mom
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 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 SUILDNG INSPECTOR
See other side for state code
CITY OF SALEM
r -f�4 PUBLIC PROPRERTY
DEPAR"I'v1ENT
-•,I ,, •I; I'C �\. ,LII�,.,, ��n[t.rr � �.�I I �[. \L�,;�, .,. I . _I � _
s'... III '['8-�14.•/;4; ♦ I`�Y: 'i 78JJ:'ESL,
Construction Debris Disposal Affidavit
(required li)r all demolition and renovation work)
In accordance %%ith the sixth edition ofthe State Building Code, 780 CNIR section 111.5
Debris, and the provisions of IGL c 40, S 54;
Building Permit rf is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal Facility as defined by MGL c
111. S 150A.
The debris will be transported by:
f name of hauler)
The debris will be disposed of in
Oame of facilily)
(uddress of facility)
signature of permit applicant
,la[e
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