64 HATHORNE ST - BUILDING INSPECTION '7 The Commonwealth of Massachusetts
Board of Building Regulations and Standards CI'1'1' OF
YY Massachusetts State Building Code, 780 C'NIR SALE
Reviwd ilnr
Building Permit r\ppiication "ro Construct. Repair, Renovate Or Del uli h a
One-ur Tivo-Fantil,v Dm elling
This Section For Official Use Only
Building Permit Number: Date; plie
luilding O licial(Print Name) Signature Uuk
SECTION 1:SITE INFORMATION
Prot'erty Address: 1.2 Assessors,Slap& Parcel Numbers
6v
I.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District I'rupused Use Lot Area(sy 11) Frontage(II)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required I Provided Required I Provided Required Provided
1.6 Water Supply:(M.G.L c,40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Check
Public❑ Pncate❑ Lone: _ (Theckit' �cs❑de Flood Gone? Municipal❑ On site disposal system ❑
SECTION 2: PROPE OWNERSHIP1
.1 Ownert of Record• / `! y,��� ,
�res �A T{1i4I1/1—dl�rT/�lClfl y�7'�/I7ff S()/t/Yfr MA- oiln>
Nanc(Print) City ate.ZIP
4� HA , 17P S41-el � L -901 1 NI .r_ C�ii�hii+n rrirra./<u y
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ umber of Units_ Other ❑ .Specify:
OriefDescription of Pro osed Work-: u/ " 077y
! ✓r'I J 7 u
SECTION J: ESTIMATED CONSTRUCTION COSTS
Meat Estimated Costs: Official U Only
(Labor and Materials) Use y
I. Building S I. Building Permit Fee: S Indicate how ree is deIned
2. Electrical S ❑Standard City/Town Application Fee
❑Tutal Project Cost'(Item 6)x multiplier _ x
1, Plunthing S a. Other Fees: S -a. \lechanic,d III\'.1C) S GKLisl::mieal (Firelcisiun SsUJ Total \II Fees: S
Check No. ('heck amount: (',uh \motmt:
Tidal Project Cost: S d U --— --
S ❑ Paid in Full 0 Outstanding Bal:mce Doc:
SECTION 5: CONSTRUCTION SF.RVI(TS r'
5.1 (bnstructiun Supervisor License(CSI.)
License Nmuhar ---- --- fspiruinu Dane
N;une of CSI. I I„Ider
I ist C'SI. I)pc lieu haluwl.__
------------------------ ----------- 'I'.%pe Description
No. .u1J Slrccl
U l OlrestrieteJ I IhtilJin n,i l0 13.0110 eu. 111
It Restricted Lt;2 Paunil bwdlin
l'itvi l'uwn.Stale,LlP M1I %lasun
RC It,x1 in C'uvurin
W'S Window an'SiJin
SF Solid Fuel Iluming Appliances
I Insulation
felt hung Ifnlail address U Demolition
5.2 Registered Home Improvement Contractor(HIC)
IIIC Registration Nunlher Expiration Unto
I IIC C'ompun) Nantc or IIIC Itagistmnt Nunn
No, and Street Email address
City/Town.State,ZIP rele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,e. 152.4 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
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 Nature(F.Iccuunic Signature) Date
SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION
rZByenter' name below, I hereby attest under the pains and penalties of perjury that all of the in rmation
s application is true and accurate to the best of my knowledge and understand! /
Print Ow wr'ior AothurircJ Agent's Noma(lilactrunic Signature) Data
NOTES:
I. .\n Owner who obtains a building permit to do his.her own work,or an owner who hires an wvcgistered ountractur
I nut registered in the Hunle Improvement Contractor(HIC) Program),will no have access to the arbitration
program ur guanutty fund under I.G.L. c. 142A. Other important information on the HIC Program can be found at
„ .,I Information on the Construction Supervisor License can be found at 11.15:
i. \\'lien substantial work is planned,provide the information below:
Total !lour area Isy. ft.) _ 1 including garage, finished basement attics,decks or porch)
Gross liv ing area 1 sy. It.l _ . _. Habitable rounn count
� \timberoflireplaccs, Numberofbcdrooms
' i \norther othathrounu _ _ _ Number of h:dl'b;nhs
I\pu of boating iy stem _ . - - Number ot'decks, torches -
I'\pe Uf eO,tlllg i\ilelll I'Ilcloied - __(lpell
t. "1'oial Project Square Footage'nlay he SuhSlinacd for"1'oml Project Cost"
CITY OF S.U-ENf, AUSACHUSETI'S
BLLWLVG 0EP.1RTtE`T
I 20 W.UHNGTON STRE$r, J40 FLOOR
ILL (978) 745-9595
KI\CSIERLEY DRISCOLL FAX(978) 740-984
.MAYOR THO.mw ST.PMUA
DIRECT"OF
PLSLIC PROPERTY/Bt: pLYG CO-%NISSIONEX
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 1 I I.S
Debris, and the provisions of MGL a 40, S 54;
Building Permit M 1 is issued with the condition that the dcbris resulting from
1 1, S 1 SOA.
11 work shall be disposed of in a properly licensed waste disposal racility as deffncd by MGL c
The debris will be transported by:
(n:+me of hauler) (�
The debris will be disposed of in
n �,y_�- erg 7 ,JT ,e ..s i Gam✓ y..
(iddrrff orraaLty)
119" ure of permit ippluant
Lte
CITY OF SAL.E.Ni
PUBLIC PROPERTY
DEPARTMENT
u.a.assr o�smu ,
Vwrae 1 b WMMs.TM mast•SiLLA[K MML40&SWM Or VO
nX.t-&746-95"• V.%X 178.7469W
HOMEOWNER LICENSE EXEMMON
Please Mat z
Dots 11 /3U I
Jof,c«adoe Ff4 t a? J� 444
Home Owner Addraw G y (41,4ti�rn t r-1 f(e M/Ui
Home Owner Telephone - J- qr 2 f,
Presst Mailing Address h V I E yn L i4ru-h 5AL:!�
The current exesmpdon of"Homeowners"was extended to include ownaroccupied
dwellings of two Units or teas and to allow such homeowners to engage an individual for
hire who.does not possess a licasso provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Pown(s) who owns a parcel of land on which hWsbe raids or intends to resider on
which there is, or is intended to bs,a one or two limily dwelling, attached or detached
structures accessory to such use and/or farm structures, A person who constructs more
than are home in a two year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building OQleial,on a form acceptable to the Building
Oillcial, that helshe be responsible for all such work performed under the Building
Permit
The undersigned "homeowner"assumes responsibility for compliance with the Stitt
Building Code and other applicable bylaws and reguladons.
The undersigned "homeowner"certifies that halshe understands the City of Salem
Bwlding Department minimum inspection procedures and requirements and that he/she
Mill comply with said procedures and requirements
HOMEOWNERS SIGNATL
APPROVAL OF SUILDENG INSPECTOR
See other side for state code