72-74 HATHORNE ST - BUILDING INSPECTION (2) 4 70
141
The Commonwealth of Massachusetts
�� '• Board of Building Regulations and Standards CITY OF
�i Massachusetts State Building Code, 780 CMR SALEiM
Revised Mar Zl)l l
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or T ivo-Farnily Dwelling
This Section For Official Use Only
Building Permit Number. Date plied:
to
Building Official(Print Name) Signature Dal
SECTION I:SITE INFORMATION
FI [
Ptro ert At(r(1ess• y 5. I 1.2 Assessors Map& Parcel Munhers r Zff
_ Syr+
yv Is this at accepted street?yes no Map Number P:ucel Number r m
\ N
1.3 Zoning Information: 1.4 Property Dimensions:
%Doing District Proposed Use L.ot Area(eq ti) -- 17nmtage(It) N C)
rn
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Reyuircd ProvidcJ ZRequired Provided
3
1.6 Water Supply:(M.O.L c.d0,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal Systenc
Public W Private❑ zone: _ Outside Flood Zone'? Municipal Von site disposal system ❑
Check ifyes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: SG J-Tr d� C M < O/
7 ( , l
Name(Print) L _ City.Sude! ZIP
No.and Street "falcphonc Gnail�2Addr
ss
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ E.xisting Building Owner-Occupiel ❑ Repairs(s) ❑ r\Iteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Spccil'y:_ _
Brief Description of Proposed Work'':
SECTION 4: ESTIjMATFD CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials) y
P
g $ I. Building Permit Fee: $ Indicate how tee is determined:
cal $ ❑Standard City/Town Application Fee
❑Total Project Cost(Item 6)x multiplier xng $ � Other Fees:nical (1IVAC) $ List: _nical (Fireon) $ Total All Fees:Check No. Check Amount: - Cash Amount:. Project Cost $� 7C 0 [)aid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
vJ „d License Number Expiration Date
Nmne of CSL Holder
List CSL Typo(see below)
No.and Street "type Description
11 Unrestricted(Buildings up to 35,000 cu. ft.)
R Restricted 1&2 Family Dwellin
Cityltown,State,ZIP M Mason
ry
y RC Rooting Covering
o, WS Window and Siding
^��/ nr G ,,/,y/ jy SF Solid Fuel Burning Appliances
V �R60 * D � /V � � /O I Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC)
Ii
HIC Company Name or IiIC Registrant Name IC Registration Number Expiration Date
No.tmd'Strect,r F.muil address
City/Town, State,ZIP Telephone
SECTION 6: WORKERS'CONIPENSATION INSURANCE AFFIDAVIT(NLG.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
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.
Print Owner's Name(Electronic Signature) Dale
SECTION 7h:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereb attest under the pains and penalties of perjury that all of the information
co tained in this app ication is true a d ac orate to the best of my knowledge and understanding. I /
U�
I rint Owner's or Authorized Ageirrs ITame(file( runic Signature) Date
NOTES:
I. 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 1
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.nlass.aov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dps
2. When substantial work is planned,provide the information below:
Total Floor area(sq. 11.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. R) Habitable room count_
Number of fireplaces ___ Number of bedrooms _
Number of bathrooms _ Numberofhalf/baths
Type of healing system Number of(leeks/porches
"type of cooling system_ Enclosed___Opel,
3. `Total Project Square Footage"may be substituted for"Total Project Cost"
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AGCOUNT4 q HOW PAID
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.6ABANCE /��' MONEY 'Itep l.7 61 j' YY
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CITY OF SALEM, MASSACHUSETTS
BUILDING DEPARTMENT
120 WASHINGTON STRE ET,3 FLOOR
�� :nvsn TEL. (978) 745-9595
FAX(978) 740-9846
KIMBERLEY DRISCOLL
MAYOR TY IoMAs STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COND USSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date
Job Location
Home Owner Address t
Present Mailing Address
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 hat he/she understand the City of Salem Building Department
minimum inspection procedures and re Irements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR
CITY OF SM-.E�1,f >tiL-155;\Cj-iUSET'I-S
ECILDLNG DEP.IRTIL&rT
130 CV.ISHLYGTON S-MEzT, }'°FLOOR
TtL. (973) 745-9595
Kl1LDER1 Y DRISCOLL FVC(J73) 7.10-934S
LAYott
T'riosus SrPtP—gltg
DIRECTOR OF PUoLIC PROP ERTY/a E:MDLNG CO\OIISSIONEZ
Construction Debris Disposal A111davit
(required for all dcmOlitiOn and renovation work)
In accordance with the sixth edition of the State Building Code, 730 QMR
Debris, vid tho provisions Of tAfGL c 40, S 54; section l l 1.5
11 Building permit N is issued with the condition that the debris resulting from
work shall be disposed of in a properly licensed waste disposal facility as defined by &ICL c
1
l 1, S
The debris will be Iran ported by;
(it�nu of hauler)
The dchris will be disposed ot'in ;
(111110., at'tuaility)
tynu rnu(p<rtnit.tpplieatu
n ,