5 HENRY ST - BUILDING INSPECTION Q The Commonwcallh of Massachusetts
(� Board of Building Regulations and Standards Town of
Massachusetts Stale Budding Code, 786 CMR. 7'"edition Building Deptt
Budding Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Tico-Funrih Duelling
This Sectipri For Official Use Only
Building Permit Number: Qale Applied:
Signature: 6---r--
Budding Commtsswner Inspector of Bmldi gs Data
SECTION I: E INFORMATION
1.1 Property Address: V 1.2 Assessors Map d Parcel Number
D
1.I a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning information: 1.4 Property Dimensions:
Zoning District Proposed Use La Area(sq R) Frontage(R)
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.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal eon site disposal system O
Public V Private O Check if esEl P Ip Y
SECTION 2: PROPERTY OWNERSHIP'
N Address for Service:
978 Zi o - z373
Signatwe Telephone
SECTION l:DESCRIPTION OF PROPOSED WORKS(cheek all that apply)
New Construction O Existing Building O Owner-Occupied 0 Repairs(s) ❑ 1 Alteration(s) O 1 Addition
Demolition O 1 Accessory Bldg.O Number of Units_ her O Specify:
Brief Description of Proposed Work': DI d
s
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building S To O , Q b 1. Building Permit Fee: S Indicate how fee is determined:
O Standard City/Town Application Fee
2 Electrical S ❑Total Project Cost(Item 6)x multiplier x
J Plumbing S 2. Other Fees: S
a. Mechanical IHVAC) f List:
5 Mechanical (Fire S Total All Fees: S
Su ression
Check No. _Check Amount: Cash Amount:_ '.
6 Total Project Cost: S S706 , d0 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Evpoution Date
N.4nic of CSL- Helder Lit CSL Type(see below)
AL
i Description
Address
U Unrestricted(up to)5,OI)0 Cu. Ft.
R Restricted 1&2 Family Dwellin
Signature M Masonry Only
RC Rcstdennal Roofing Covering
Telephone N'S Residential Window and Siding
SF Residential Solid Fuel Illumine Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I. c. I52.J 2SC(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 ARdavit Attached? Yes.......... O No...........O
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
Fauth
R'S NTOR CONTRACTOR PLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
to act on my behalf,in all matters
o A authorized by this building rmit application.
of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
,as Owner or Authorized Agent hereby declare
tatements and information on the foregoing application are true and accurate,to the best of my knowledge and
l l�n_ -7/2,3 /Via
Signature of Owner or Authorized Agent Date /
(Signed under the l2ains and penalties of perjury)
NOTES:
1. 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 a/have access to the arbitration
program or guaranly fund under M.G.L. c. I42A. Other important information on the HIC Program and
Construclion Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS,respectively.
F2. When substantial work is planned,provide the information below:
ors area(Sq. Ft.) (including garage, finished basement/attics.decks or porch)
ing area(Sq. Ft.) Habitable room count
of fireplaces Number of bedrooms
f bathrooms Number of halfbaths
eating system Number of decks/ porches
oolingsystem Enclosed Open
l Project Square Footage-may he suhslitulcd for 'Total Project Cost-
CITY OF SMYD4
PUBLIC PROPERTY
DEPARTMENT
..%"VM t 3e W.9uncron 2MMT 9%4,ff- Vw�0111[i7S 017'0
M 9-9-745.9s"•#;.kx 9'L7J67aN
HOMEOWNER LICENSE EXEIMMON
Plea"gPr( I q
Dab
Job Loeaaots
Home Owner Address !9 AA e
Home Owner Telephone cri 91 Z) 6 _ 2,973
Present Mailing Address S He/911J Y S 1
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 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 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 understands the City of Salem
Building Department minimum inspection p educes and requirements and that he/she
will comply with said procedures and requi ents.
HOMEOWNERS SIGNATURE
,APPROVAL OF BUILDING INSPECTOR
Sce other side for state code
CITY OF SALEM
i PUBLIC PROPRERTY
DEPARTMENT
M l_'Q W.WH\GI'ONSTN LET • SAI FM, Ili It 'I%Ili
fr1:978-74 9;95 ♦ 1':\s:97S.74:9846
i
Construction Debris Disposal Affidavit
(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 c 40, S 54;
Building Permit tt __ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
l l 1. S 150A.
The debris will be transported by:
D4 J MOPP-1 U-
(name of hauler)
The debris will be disposed of in
-......__-_ (name of facility)
(SvJ�
taddress of facility)
signature of permit applicant
date
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