72 HATHORNE ST - BUILDING INSPECTION ills - l �1- 130 � GKtI $ 2 � Ils�
The Commonwealth of Massachusetts RECEI ED
' Board of Building Regulations and Standards INSPECTIONA SE
Massachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or rocAus a. /A It: 03
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name) Signature Nate '
SECTION 1:SITE INFORMATION
1.1 Property Address: �kkA JI(\e 1.2 Assessors Map&Parcel Numbers
L la Is this an accepted street?yes ✓ no J) Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zonine Disuict Proposed Use Lot Area(sq 11) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Requred 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❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'ofRecord: ,Sr. IP,�. 1 ' ,4 6�
Sc str �/elb< (J1
Name(Print) City,State,ZIP
-1k WA7+�, k S-V 11d /9l6 (34,ioO�kod
No.and Street Telephone Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied X( Repairs(s) ❑ 1 Alteration(s) ❑ TAddition ❑
Demolition f8. Accessory Bldg.❑ 1 Number of Units I Other ❑ Specify:
Brief DescriRtion of Proposed Work':
Ck[de cl3 t5V,r S Ti7 P a
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
[3 Standard City/Town Application Fee
2.Electrical $ ❑Total Project Costs(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List
5.Mechanical (Fire $
Suppression) Total All Fees:$
�� �1 Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ Uv ❑paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
r5nstr, n Supervisor License(CSL)
License Number Expiration Date
er List CSL Type(see below)
„ TypeWBum�ingApphm�s
Description
U Buildin s u to 35,000 cu.ft.
city/Town,State,ZIP
R &2 Famil Dwellin
M
RCverin
WSd Sidin
SFurning Appliances
I Insulation
Tele hone Email address TDDemolftion
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name -Registration Number Expir ation Dale
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 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
Bye ering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contai ed in this ap icatio is true and accurate to the best of my knowledge and understanding.
W ►
Prm er s or Authorized Agents Name(Electronic Signature) Date
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 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
www.mass.gov'oca Information on the Construction Supervisor License can be found at www.mass.<=ov/dps
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"maybe substituted for"Total Project Cost"
CQ
f/ QTY OF SALEM, MASSACHUSETTS
�yl BUILDING DEPARTMENT
1{K Sa t �tl
\3 -. ,✓ c' 120 WASHINGTON STREET,3AD FLOOR
TEL. (978) 745-9595
KIMBERLEY DRISCOLL FAX(978)740-9846
MAYOR THomm STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING 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 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:
�\N A S 4 LCCA--L-�
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applic nt
Date
CITY OF SALEM, MASSACHUSETTS
BUILDING DEPARIbiL•NT
y lh" 120 WASHINGTON STREET,3"D FLOOR
�` ? sx TEL. (978) 745-9595
FAX(978) 740-9846
KINIBERLEY DRISCOLL
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMNIISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date . I \
Job Location Ja '—)y (tinn�`��
Home Owner Address ,l!, f`Me
Present Mailing Address o !nl'
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 V '
APPROVAL OF BUILDING INSPECTOR
Unofficial Property Record Card http://salempatriotproperfies.conVRecordCard.asp
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Narrative Description of Property
This property contains 0.065 acres of land mainly classified as Two Family with a(n)Multi-Garden style building,built about 1914,having
Vinyl exterior and Slate roof cover,with 2 unit(s),10 room(s),4 bedroom(s),2 bath(s),0 half bath(s).
Property Images
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Disclaimer:This information is believed to be correct but is subject to change and is not nleed.
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