6 HENRY ST - BUILDING INSPECTION ,, --- I'lie Commonwealth of M:usachuscits
y: ', Board of Building Regulations and ScutJarJs CI FY OF
"I 'r Massachusetts State Building Code. 78B C NIR tiALG,\I
'L,...
Building Permil Application 'ro Construct. Repair, Renovate Or Demolish a
One-or rn'n-k"amilr Dtrelliuir
This Section Fur 011 icial Use Oul
Building Permit Number. _ Date 1 lied: r
-MIe✓
lhiilding O1licial( riot Nmne) Si u Date
SECTION 1:SITE INFORIIIATION
1.1 Property Address: 1.2 Assessun blap di Parcel Numbers
1.1a Is this an occe tad street? 'a ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Propose)(Jse Lot Area(sq 11) Fronlage(11)
1.5 Building Setbacks(re)
From Yard Side Yams Rear Yard
Required Provided Required Provided Required I'roviJed
1.6 Water Supply:IM.G.I.c.40.§») 1.7 Flood one Information: 1.8 Sewage Disposal System:
Public 0 Private 0 Zone: _ Outside Flood Zone? Munici d 0 On Bile Jis YaI tl stem 0 Check iF es0 D W >.
SECTION2: PROPERTY OWNERSHIP
2.1 Owner'of Re
cgrd:
c� d �i✓,/ H O/9 7,0
N;unc(Prim) ('ity.state,ZIP
35 6 73.2�1 Ca✓cam/IaY�C/ ✓ S.o /-
Nu9
.and Street I /'1L.�elephune Email Address �J
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building 0 Owner-Occupied CI Repoirsls) Alterallon(s) ❑ Addition ❑
Denolilion 0 Accessory Bldg.Cl Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work : u oaa
SECTION J: ESTIMATED CONSTRUCTION COSTS /
liens Estimated Costs:
i l.abur and Materials) Official Use Only
i. Building S I. Building Permit Fee: f Indicate haw fee is determined:
'. Fleorical S ❑Standard City'Tusvn Application Fee
O Total Project Cost'(Item 6)x multiplier _ _ x
I ?. Plumbing S 1. Other Fees: S — - -- -
J. MMI.Inical ill\'.\Cl S List:
9 \Icchanieai 1Firc — — -- --
`u,+rcisionl S Total All revs: S
o' Chak No. ('heck Amount: C.ish \mount:
! 'utal Project Cost: 1i DOD -- _.._.
❑ Rlid in Full 13 Outstanding Ilal;utce Due:
SE("PION S: ('oN.S I'RUCfIO,N SERN'R F:S
5.1 Construction So pen'isur License lC'S1.)
I icons¢ Numhar li�piratiou Date
N;une of l'SI. I lulder I ist C51. I\Pe(sec hcloo)
No and Street tl I iorestnocd I Buildings utl to {S,UIItI cu. Il.l
R Restricted NQ F.unil Docllin
Cod'oau.slate.LII' ..—._--"_—.. . . .vl 11laiun
RC Roolin Oncrin
_ µs µ'iIIJuw;nd sitting
SF solid Fuel Miming Appliances
I I buluti at
1'ck hone Fnlail address D Demolition
!.2 Registered home Improvement Contractor(HIC)
IIIC'ltcgisualion Nunlher lispirutiun Uwe
I IIC C'ompan) Name or I IIC Itegislrwu Nanle
No.and Strcel Email address
City/Town.State ZIP Talc hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 132.1 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 Issuance of the building permit.
Signed Affidavit Attached? Yes .......... D No...........Cl
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
h 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.
Print Owners Name(Elcorunie Signuturu) Date
SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
coat 'ned in this application is true and accurate to the best of my knowledge and understanding.
,r ,� A c yc4 tc ;
I1rin owner'sort\tithoriieJ,\III In4, amulh.leclrunteSigmuuro) Dale
NOTES:
1. .\n Osvner who obtains a building permit to do his her own work,or an owner who hires an unregistered contractor
Inot registered in the Hurtle Improvement Contractor MIC) Program).will mr have access to the arbitration
program or guaranty fund under M.G.L.c. 1 4_'.A. Other important information on the HIC Program can be round at
rn.r•s n .1 l Information on the Construction Supervisor License can be found at „ s,t n•1• :;% III),
2. \Then substantial wurk is planned,provide the intbrinatiun below:
rota) flour area I sy. I1.1 " I including garage, finished basement attics.Jerks or porch)
Grosi lining area 154 11.1 ___""" _ _"." . Habitable room count
\unlhcr of lircplaccs .... \unlher of bedr oms
\muherol'hathrooms _ Numberothalfhall's
1)Ilk:ai heating i)Stnn Number of decks: porches
I\pe al �Jtth llg i\itelil
I:ncloscd Open
t 'I,ddl I'nijeil Stluare Foolagc"nl;l) he stihitituwd Ii,r Tk1al I'rojecl Cost"
I '
'� }~ CITY OF SM-E.M
PUBLIC PROPERTY
DEPARn, LENT
savor i 7a v.�ww,�rnaasr�soot V�a�oRsartr et r-0
nL 9'LIlL7s"•Fit 97L7467W
HOMEOWNER LICENSE EXEMPTION
Pleass "I
Des
Job Locadas to //C f-
Rome Ownetr Address 57L � 4224D/9 7d
HomeOweirTelephooe 9-- S— 6 a —335r 9 3,Z
Preach Mailing Address cN s Teu-le—A,4 M d•
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Unit@ or fens and to allow rich homeowners to engage m individual for
him who.does not poaaese a licenser provided that the owner act@ as supervisors
DEFINITION OF HOMEOWNER
Pc=n(s) who owns a parcel of toad on which he/she resides or intends to reWder on
which them is, or is intended to be,a one or two family dwelling, attached or detached
structures accessary to such use and/or Perm 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
Ofllcial, that he/she be responsible for all such wort performed under the Building
Permit
The undersigned "homeowner"names responsibility for compliance with the State
Building Code and other applicable bylaws and regulations.
The undersigned"homeowner"certifies that he/she understands the City of Salem
Building 0epartment minimum inspection procedures and requirements and that he/she
Will comply with said procedures and requirementu /7
HOMEOWNERS SIGNATUM
APPROVAL OF BUILDING INSPECTOR
See other side for state code
^� CITY OF S,VZNl, AUSACHUSETTS
RUNG DEPAMLENT
I_'0 WASHLNGTON STIM, )ia FZ,OOIt
FAX(918) 744984
.'U1(BF_Rr Y OUXOLL
MAY01 MO Wl ST.PMXAS
0"=C4 OP PC aUC PROPERTY/gt:Q.DLNG CO.10iiSSION Eb
Con9tructlon Debrla 013posal AiRdavit
(required for all demolition and renovation work)
In accordance with the sixth edition otthe State Building Code, 780 C,14R section 111.1
Debris, and the provisions of MOL a 40, S 54;
Building Permit AI is issued with the condition that the dcbiis resulting from
This work shall be disposed of in a property licemed waste disposal facility defined by,bICL c
I I I, S 150A.
The debris will be transported by:
`(name ofhaular)
The debris wi 11 be disposed of in
l.�,lse�✓1S� Ind ,
( me or! P rt; lyj
_ P
(iddren of ru IT,ry)
4Q V �0 d
u�namreofpermitrpphcint —