80-82 HATHORNE ST - BUILDING INSPECTION �7
t The Commonwealth of Massachusetts
9 Board of Building Regulations and Standards CITY OFSALEM
Massachusetts State Building Code, 780 CMR Revised Blur 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
Cn This Section For Official Use only
I Building Permit Number: Date Applied:
13
Il 14 Io
Building OfOcial(Print Name). -;Signature , Date
SECTION 1:SITE INFORNIATION:
1.1 P o erty Address: o• 1.2 Assessors blap&Pnrcel Numbers
-
I.la Is this an accepted streets. yes - no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zuning District Proposed Use Lot Area(sq Ill Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yams Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal Cl On site disposal system ❑
Public❑ Private❑ Check if es❑ P
SECTION2: PROPERTYOWNERSHIPI'
2.1 ert ZRecord: µ slct_( Q
a Cs11q
e(Print) 1A City,State,ZIP \ l
�s of o P g3�-lfl3i -t�bd dutausC`G eAiCaAk-oA/V /
No.and Street Telephone Email Address
1 SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
/jt1 f/J New Construction 0 Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Altemtion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ NumberofUnits_ Other ❑ Specify:
Brief Description of Proposed Work-: v ex bi qov o 3 d
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Ofllcial Use Only
Item Labor and Materials) -
1. Building S 9' OJ 1. Building Permit Fee:5l I D Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical 3 (9 PQ9 .03 ❑Total Project Cost'(item 6)x multiplier x
3. Plumbing S o. �`�' 2. Other Fees: S
d. Mccluanical (HVAC) S �( List:
5. %le"chanical (Firz
ssiun) i Total All Fees:S
Check No._Check Amount; Cash Amount:_
G.)Dial Project Cost: i aFJ LW ,d 3 ❑Paid in Full ❑Outstanding Balance Due:
Jai!) .12) /P�s_
SECTION 5: CONSTRUCTION SERVICES !
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder List CSL'rype(see below)
Type- Description
No.and Street
U UnrcsiricteJ But in s tip to 35,000 cu. tt. .
R Restricted I&2 Family Dwelling
Cily/Pown,State,ZIP M Mason
RC Raofin Coverin
WS WindowandSidin
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered dome Improvement Contractor(HIC)
HIC Registration Number Expiration Date
IIIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town, State ZIP Tele 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 Isimance of the building permit.
Signed Affidavit Attached? Yes ..........❑ No........... 0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN"
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING.PERMIT'
I,as Owner of the subject property,her by authorize
t9 act on m matters rel the to work authorized by this building permit application.
�l l-k
Print Owner's Millie(Inlectrtnic Signature) Date
SECTION 7b:O t AUTHORIZED AGENT DECLARATION
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agcnt's Name(Electronic 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
program or guaranty fund under I.G.L.c. 142A.Other important information on the HIC Program can be found at
www mass cov:'oan Information on the Construction Supervisor License can be found at www.mass.^ov:'Jas
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage,finished basementlattics,decks or porch)
Gross living area(sq. It.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
rype of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted tur"'Total Project Cost"
11a WAMN=WBAMT,31°Aoat
gn�trl�rnwsaXL PAr 74aM*
MAY DXUUS7 WM l
D c�>�ressas�r/aw�cacaoa�a�s
Construction Debris Disposa/Affldovit
(required forall demolition andrenovation workj
in accwdmw with the sbcth edition of dw State Buff W Code. 7W OW Secdon ills debris;
and dw provisions of mGL coo,S 54, hdift Permit if is issuedwM the
conditlon that the debris Multfg from this work shag be disposed of in a pmpe*licensed
waste deposit badgtyas defined by ANSI.c 111,S 1S6A.
The debris will be transported by.-
(name of hauler)
The debris will be disposed of in:
(name of fadlity)
(address of facility)
Minatur of applicant
l
Date
aCITY OF SALEM, MASSAaJUSE TTS
BUILDING DEPARTMENT
120 WASPIINGTON STREET,3"D FLOOR
EL.(978)745-9595
KIMBERLEYDRISOOLL FAX(978)740-9946
MAYOR TYiOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT.,
Date
Job Location
Home Owner Address_ s
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 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
APPROVAL OF BUILDING INSPECTOR