38 HAZEL ST - BUILDING INSPECTION (2) =� __ --- I'he C'unmwttscc;lllh ol•Massachusclt
I i ' Board of Building Regulations and Standards CI I'Y OF
tl' i Massachusetts State Building Code, 780 CNIR s.\LG,\I Building Permit Application 'ro Construct. Repair, Renovate Or Demolish a Rel'isei/ I6u•:u//
one-eir rw(i.blanti/v Dmelint.q
This Seeiun Fur Olticiul Use Onl
Uuiiding Permit Number: —_ Da a Applied•
�" "
Ilu;idmy Olrmal(Print Mane) Sig;ut
)ole
SECTION I:SITE INFOR31ATIO
I.I Property AJJres\�Q �� 1.2 AssessoN di Parcel Number --
\N/ �1 q-� r.Ar
L I s Is this an acre ted street? a no idap Number Parcel Numhir
LJ Zoning Information: 1.4 Property Dimensions:
Zoning District Fnnposad —uie Lot Area(sy II)
1.5 Building Setbacks(R) fronmge(Ill
From Yard Sidc Yanks
Required Front
Required Provided Rear Yard
Reyuind Provided
1.6 Water Supply:(M.G.1.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Privale❑ Zone: — Outside Flood Zone?
Check if es0 Municipal❑ On site disposals)stem ❑
2.1 lwntrl of Rec/o�r
SECTION2: PROPERTYOWNERSHIPI
ame(Print) ^�
�,�l_1 l sa✓��-- - / L I
/ we.,mJ Stmet
relephone Email Address
SECTION X DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repuirs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other
Brief Description of Proposed Work':_ — p..rly.
Lv
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Ilan Estimated Costs:
(Labur nd .Materials) OMCIJI Use Only
I. Building S I. Building Perniit Fee: S Indicate how tee is determined:
`. Flectrieal S ❑Standard City/Town Application Fee
i I. Pltunhing S ❑Total Project Cast'(Ilem 6)x multiplier .x
Other Fees:
4. .Medianical ill\ \C) $ List:
\Ieehanical ifire --
S --- --- —tiu l aessianl Total .\Il Fres: S -
0 Total Project Cuss Z Check No,. ('heck Amount: l'.uh \tutor:❑Paid in Full
U❑ msuuding Ilal:ucc Due:
sli PION S: ON,SI-Ittic-t-ION SERVICES
('onst ruc I lon Supervisor License
D;IW
\ante of l'SI.
1 10
R
K Roolin Co%crin
%k S %kindo%%, ind Siding
F Solid I:ucI turning Appliances
S
I Insulation
:owil address D Demolition
sale hunt
Improvement Contractor(HIC)
S,I Registered 110 ---
I IIC tulliwation Nuini 1i.\Ilirulion Wig
I lic C,mpan) Nallic or I IIC teli Name Ernuil address
No,and Street
relic hunt,
17ro n State ZIP AFFIDAVIT(M.G.L.c. 152.0 ISC(6))
_:Cii
SECTION III WORKERS,COMPENSATION INSURANCE AFF �h provide
N A..A",uh� is'application,application. Failure with this application, Failure to provide
Workers Compensation Insurance affidavit must be completed and submitted w
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? yes ..........13 No.......
SECTION gw, 7s:T%V1;—ERAUTij-0WUT—JON TO BE COMPLET,E WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner or the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Dutt
Print owier's i(Electronic Sisnaturm)
SECTION 7b:OWNEWOR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
cot aintd in this ap lication is true and accurate to the best of my knowledge and understanding.
PC, , I
I Dam
Print 0 ir;%ut iori/c Nook NOTES.
owner who hires an unregistered witiractor
s.her own work,or an o% b co a u
arbitration I.
a u e at -3n be ound a'I
r.1111
-133 10 1
.\n 0%�Iler%Ou obtains a building permit to do hi mil-11C) Prograrrip have access to 11"Itarbitration
(not registered in the Home Improvement Cui la 1" 0 1 can be found at
tion on the HIC Program program or guaranty fund under NI.G.L.c. 141A.other inipuriant infornia e
an be found at
I Information an the Construction Supervisor License ci
—21 lien substantial work oork is planned,i ide the inturnintion below: or'lli
I including I;arnge. finished basement attics,decks or pordi I
w floor area(4 Hai rouni count
Gross living area I sq, It I .... . .. \,Ioli ol'bedrooms
I \timber of i Nlinibcr of 11;1111
\timi bathrooms \lunherol'daki, pordw5
1%lie M heating iN SICIII Ofen
1'\lie ofioolfil g S.\item ------------
for ('05C
i loial llrojQO Still3rc 1"aN he
i
CITY OF S.U-&NI
PUBLIC PROPERTY
DEPARTMENT
u.wa�at/n�•.v�
w,ve i�0 7.wr.c,,�or tn.n.sua�ws�ow rears 01 tre
ML rt74S•7s".ve7L 976746964
HOMEOWNER LICLNSB EXiti.NMION
Ptesao Mess _
Dan / • ?i
Job I ocadon .
Home Owner Addrea
Home Own.Telephone —
Ptessnt Mailing Address
Tie current exemption of"Homeowoar was extended to include*wow-occupied
dwellings out two Units Of teas and to allow inch homeownws to Capp an individual for
hire who does not possess a lieenso provided that the owner acts as supervisor.
DEFIIYIiIi TON OF HOMOWNER
Pasco(s) who owns a petrel off land on which ha✓she rssides or intends to resider on
which them is, or is intended to be, a one or two family dwelUng, attached or detached
structures accessory to such use and/or farm structures. A pawn who constricts more
than one home in a two year period shall not be considered a homeowner. Such
"homeownce shall submit to the Building OQleial,on a form acceptable to the Building
Oillcial, that he/she be responsible for all such work performed under the Building
Pamir.
The undersired "homeowner"assunses responsibility for compliance with the State
Building Coda and other applicable by-laws use/reguladons,
the undersigned "homeowner"certifies that he/she undentands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
Will comply with said procedures requiremersm
HOMEOWNERS SIGVATL'RE
IK
APPROVAL OF gU1LDING WPECTO
See other side far state coda
CITY OE S'UzNi, Aus.1CHus& TS
JLULNG OEf.1AT118.`r
1'0 T-UHNGTON STIM, Jw FLoOA
I-RL. k973) 745-9591
110EAr V OUWOLL FAX(975) 74984
NCAYOIt rkaxw S-r.PMUX
[JtA&:TOA Of Pt.Stic P40PEATY/sILMO YG CommISSIOVEA
Construction Debris Disposal Affidavit
(required for all demolition and rcnovation work)
fn accordance with the sixth edition of the State Building Code, 190 CZ R section I 1 I.J
Debris, and the provisions of MGL o 40, S 34;
Building Permit At is issued with the condition that the dcbris resulting from
1 11
.
, 3 I JOA.work shall be disposcd of in a properly licemed waste disposal facility as deBncd by NIGL c
rho debris will be transportcd by;
0
(mans ut hwlar)
The debris will be disposed of in :
'J"Ims Of �Yl
' ulpermit iPPI, int