69, 71 HAWTHORNE ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State I BuildingCode, 780 C'MR, Tn edition OF SALEM Revised Junuury
Building Permit Application To Construct, Repair, Renovate Or Demolish a
�n One-or Two-Fumily Dwelling
r lA t1'h This Section For Official Use Only
Building Permit Numbe . Date Applied: i' 41 t
Signature: �ir • ` r.
Building Commissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
6q . l1 k'W-7HV L(Yt S7,
\ J I.I a Is this an accepted street?yes_ no Map Number Parcel Number
�^ ) 1.3 Zoning Information: 1.4 Property Dimensions:
�lC\ Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards 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?
Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownert of Record: N✓IwT/f b t {/L
,Jt�sC— Csr7n�Z— (a'9- 7/
37
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied V I Repairs(s) ❑ 1 Alleration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.O Number of Units I Other ❑ Specify:
Brief Description of Proposed Work':
72EFCA6: el-rC'�� C443/067 S. SST s¢ z.✓�� �L.,OY -
AL. b 77(iS /a/ al"HII&D9eNf t 7>9rn7 LvALLt 4 C2�:// 1
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S Z _ qD0 I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
12.
Total Project Cost'(Item 6)x multiplier x
J. Plumbing S 9,5� 0 OtherFees: S
J. Mechanical (FiVAC) S ist:
5. Mechanical (FireSSu ression otal All Fees: Sheck No. Check Amount: Cash Amount: `3 Z5
6. Total Project Cost: S Paid in Full ❑Outstanding Balance Due:
GA i? Gay�/ rvGVkn� 7 �l 3 v H -z q o /
SECTION 5: CONSTRUCTION SERVICES ' 1
5.1 Licensed Construction Supervisor(CSL) 08-A,1 9 3 D
�1J V,�, _ License Number lixptration Uatn
Name of CSL-IoISJer SZ / List CSL Type(see below) & !w
5V ��w r Description
Ad s U Unrestricted u to 35,1100 Cu.Ft.
R Restricted 1&2 FamilyDwelling
Signature pc� M Maso Onl
7 1.3e>r �-y0� RC Residential RoofingCovering
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Rggb�l�td Holmproverpyp�nrt�Contractor(HlC), /Z��� '3
Registration Number
HIC Compan Nam;!or IIIC Registrar Name
0
AJJrc �y.—q Expiration Dale
�=T
Signature telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 25CM)
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 .......... 0---�No...........O
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.
-Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1 ,as 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
behalf.
Print Name
Signature of Owner or Authorized Agent Date
Si ed under the airs and penalties of 'u
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 no 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 110.116 and I IO.RS,respectively.
2 When substantial work is planned,provide the information below:
Total Iloors 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"
CITY OF S.U.&A liLUSACHUSETTS
B( RDLYG DEPARTMENT
1_0 W.%sm NGTON STRRRT. 3m FLOOR
TM. (978) 745-9595
F.%x(978) 740.96"
KIS®E]MEY DRACOLL TtobW ST.PMAM
MAYOR DIRWMR of FL aLIC PROPERTY/n aMLNG CO%Q0SStO'%ER
Workers, Compensation Insurance Atlldavir. Builders/Contractor/Electriclsn%iPlumben
�nnlleant Inrormatlots Please PrintL.egibly
vane Leanne+aorattrttanetvttwkvtdrrll" �,.i S Nzx-IZ <<'r.ar�Ov-Q�e-er,L/.
Address' 3
City/StattlZip. ",Y) is A.5S Phone* ILI'��� U/
.\re you an employer!Clwek the apprepeiate beat Type of proleet(require*
I.UA am i mployer with 1. Q I am a a�naal emtraetor and 1 6. ❑Now conaauiWoe
employees(Adl andi'or pan-thee).• have hired the sub•corwwum y. Q Remodeling
2.Q I am a Sole propries Ix pMmm6 listed on the attaehad shoes.:
.hip well have no employes Than sub-com ossers have a. Q Dernnlition
workln fa an in as c utorbrs'eonµ inwsanca 9•
g Y >Om '• ❑OuiWing addition
INo workers'tomµ insurance S. Q We are a corperad a and is 10.❑Electrical repairs or adlditions
r quired.l ofllcers haw exercised chair
).Q 1 am a homeowner doing all work Rae erg Pr MOL I I.❑Plumbing repain or adkNtions
myself.(No worker'comp. C. IJ2,11(4).ad we have no 12.Q Reef repair
insurance required)► camµ insurance regliud.l 13.0 Other
-Any appllom this eamao NO a toes slow rle um the router OaM�q Is*weketa'dadgramdtm pulley iaawmmw e.
'16wuttaema wit&submd tab attldvir in.lodq[hay an doing All wwk ad tM Mow wlmid coamna a emm Admit a raw allhbit in.feaime wa►
4""nrsmto dr dwsk Air ban Mae istumd m aditit ad dam.Mwlty der ems of It'0t►400AMM rd[Mr w.hou. ..F petit'iwaolt..doo,
/mow ew rarPbye►rAet errrUW ARS wwaers'cowortamdrw/earreatee%r ANY rxy/oyeer, Belem/s rAepeft ewslM der
informadom
Insurance Company Name: g7,u
Policy a or Self•ina. Lie.et Expiration Dab I�;/�
!ub Siia AdWnta: (9 �� �+✓ �/� e _City/StaW2ip: 142104 "/_1T
,\track-a-copy of the workers'compsoades-pdky dach"llse page(ittawing tlr-pNel'number ad asplrstise dnb)6
Failure to%"on coverage a required under Section 2JA of MGL& I52 can lead to the imposition of criminal penalties Ora
fine up to S 1.500.00 and/or one-year imprisomment,as well u civil penalties is the farm of a STOP WORK ORDER and a flat
.rf up to S230.00 a day aysinit the violator. Ile advisod that a copy or this statement maybe rurwarded to the on ice or
Inccauyatiuru of[he AIA far inslwanee eovemae vvrifkatimt
I Jo hereby corri d tha pai a wd yenehles r/orr/ary that rAi inferwedow orevidd u0sve is true eel ewreca
�-- Data: y�yAe
offlciel tree mJyt. na.tor wrire in thin erro,to be.uwp/rtd by d'ity av foong.t//&.jet
City or ruwn: _ YermiaTicense 1__.
htuint.\uthartty (circle unet:
I lluard of IlcaUk 1. nudding Mpntment 1. city/rows Clerk J. Electrical Inspector S. I'lumbinR Impecto►
6. ttthee
L.,macl Person: _ Phase e
CITY OF SALEM
i PUBLIC PROPRERTY
DEPARTMENT
I'.U: M 111 "Illy 11 l
I:Q WA-4 V)I N kl'TO S•tl l\I. bt.\"\I I II J 1.•:1'/ .
I�il.•/.'r-'�4•liyS � 1�\!t:%7/•;+S'1!lu4
Construction Debris Disposal A171davit
(required lur 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 c 40, S .
Building Permit H is issued with the condition that the debris resulting from
this work shall be disposed of in r properly licensed waste disposal racility as defined by MGL c
l I1. S 150A.
The debris will be transported by:
tltarrte ut'hauler)
The debris will be disposed of in
a57 t�n LtJrc-;,2'
(IIaRm of 127iiyY
addms%if I'acllity)
• .Irnature of jl.rmit applicant
—T Jats
IL
CITY OF S U.ENi
PUBLIC PROPERTY
DEPARTMENT
w faFJf.YY OYY'•v�
Mwrot 130WASUNG"STREST*5416 MAS AOMMM 019V
itL 9'a•704S" F.ut 979.746904
HOMEOWNER LICENSE EXEMPTION
Please Tti�t /
Date
Job Location
Home Owner Address
Home Owner Telephone
Present Mailing AddressF
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or lean and to allow such homeowners 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 structure. 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 wort 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 procedure and requirements and that he/she
will comply with said procedure and requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code