4 HAYWARD ST - BUILDING INSPECTION (3) U��ril �2� �� � • � 3Sq ('�
1� �€GEIV
SERVI S
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards 2016. pR Ql�LE��((I
Massachusetts State Building Code, 780 CMR Rev.' 1'92l& 8
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
n This Section For Official Use Only
(� BuildingPerniitNumbeir Date. pplied:
,Building Olticial(Print Name). ignature '.: Date
_ SECTION 1:SITE INFORMATION
( 1.1 ro erty Address: 1. ssessors Map&Parcel Numbers
r
L I a Is this an accepted street9 yes no Map Number Parcel Number
I 1.3 Zoning Information: liIll Property Dimensions:
Zuning District Proposed Use Lot Area(sq tt) Frontage(R) -
1.5 Building Setbacks(R) -
Front Yard Sido Yards - Rear Yana"
Required - Provided Required Provided Requited' ' Provided
1.6 Water Supply:(M.G.L c.'40,§Sd) 1.7 Flood Zone Information: L8 Sewage Disposal System:
Public❑ Private❑. Zane: _ Outside Flood Zone? Municipal O On site disposal system ❑
Check if es❑
SECTION 2. PROPERTY OWNERSHIP'
2.1 wn r1of Record: �iW, 1 Q70
tm c(Print) _ City,State,ZIP
` /riLwM3 47 7Yl x 0/JriJ6i1 7 -
�lvdn-'dI I...:
No.and Sired Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ 'Owner-Occupied ❑ Repairs(s) ❑ I Altemtion(s) O Addition ❑
Demolition ❑ Accessory Bldg.Q Number of Units Other ❑ Specify-
--grief Description of Proposed Work-: I, Liad 5
SECTION a:ESTIMATED CONSTRUCTION COSTS
Item - Estimated Costs: - Oflleial Use Only
Labor and Materials
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
❑Standard CityfTpwn Application Fee
2.Electrical $ O Total Project Cost`(Item 6)x multiplier x
3. Plumbing S - 2?Qther Fees: S \ �l
d.M1lcchanical (tIVAC) S - List:
S.i\leehanicaI (Fire S Total All Fees:S
ressiun)
Check No._Check Amount: Cuh Amount:
6. Tt al Project Cost S O(�Q ❑Paid in Full O Outstanding Balance Due:
L4 -z
r.7 •i`""' SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
Licensa Number Expiration Date !
Name of CSL Holder List CSL'rype(see below)
Type - Description .
No.and Street -
U Unrestricted uildings ttgy to 35,000 cu. Il.
R Restricted 1&2 Funnily Dwelling
Cityfrown,State,ZIP M Masonry
RC Rooling Covering
WS I Window and Sidin
SF Soli)Fuel Doming Appliances
1 Insul¢lion
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Nome or HIC Registrant Name
No.mid Street - Email address
City/Town, State ZIP Telephone
SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152$ 2$C(6)y..
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Is§uance of the building permit.
Signed Affidavit Attached? Yes..........O No...........0
SECTION 7a:OWNER AUTHORIZATION.TO BE.COMPLETED W HEN;
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING.PEPMiT
1,as Owner of the subject property,hereby authorize
t9 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:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,i hereby attest under the pains and penalties of perjury that all of the information
contain i his ap lication is trend accurate to the best of my knowledge and understanding.
x y-1 9 avi6
Print( vner's or Authorized Agent'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
__Inot revered-in the Home Improvement Contractor(HIC)Program),will nn have access to the arbitration
program or guaranty fund under IM.G.L.c. I d 2A.Other Important information on iha H1 CProgram can be fort�nt it
www m;u�urv:'oat Information on the Construction Supervisor License can be found at www•�ns
2. When substantial work is planned,provide the information below:
'rotal 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
rype of heating system Number of decks/porches
Type orcoolingsystem Enclosed Open
3. "rural Project square Footage"may be substituted I'ar Total Project Cost"
CITY OF SALEM, MASSACHUSE M
r f BUILDING DEPARTMENT
\ 120 WASHNGTONSTREET,3"OFLOOR
TEL. (978)745-9595
KIMBERLEY DRIS FAX(978)740-9846
COLL
MAYOR TriOMAS STRERRE
DIRECPOR OF PUBLICPROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date q -/ Q-)Ld t lr�
Job Location/uurj ST• Y (2�
Home Owner Address SGw e
Present Mailing Address Ca",_0
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 INSPECIW
CITY OF SALEA A ASSACHLSE TICS
BtHLDnYC,DEPAR7mm
110 WA9MCTCNS7WT,3mRDOR
UL(978)745-9595.
BIbv16ERLE
PAX(978)740.9946
YDRISQ7Il
MAYOR 711CUMSTYMUM
DntEcrcacFpuw6noitnylBtaDmamwmcmR
Construction Debris Disposa/Afdavit
(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 4 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 c MGL 111, S 150A.
The debris will be transported by:
tCr�L �r2r, a Sct 1
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
� L
S' nature of pplicant
c _
Date
I