6 HERBERT ST - BUILDING INSPECTION (2) RECEIVED
The Commonwealth of tMassachusetts CITY OF
Board of Building Regulations and Standards 10l6 APR 1 q s�M
Massachusetts State Building Code, 780 CMR ReviseJb7trr 2011
r Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
This Section ForOfficial Use Only
Building Permit Number. Data Applied.
�' / -Building OBicial(Print Name) - Signature';
SECTION 1:SITE INFORtNIATION
I 1.1 Pro rtytdd
BRbert ST 1.2 Assessors Map&Parcel Numbers
1.l a Is this an acce led street9 yes V no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District : Proposed Use Lot Arco(sq 11) - Frontage(11)
1.5 Building Setbacks(R)
. Front Yard- . , _ Side Yaats - . . Rear Yard
Reyuined - -Providnl Requited Provided: .., Required Provided
1.6 Water Supply:(M.G.L c.'40,§54) 1.7 Flood Zone Information: L8 Sewage Disposal System:
Public❑ Private.❑. Zone: Outside Flood Zone? Municipal D On site disposal system ❑
Check If es❑ . .
SECTION1:.PROPBRTYOW.NERSHIPf,
2.1 Ot ne t of R ord, 0
I✓ S au _T n)R o)a-
me(Print t - ctly,State,ZIP
tier Y�erT 9aR__�q5-419G 7 Ulen�arrleccys e rth ,Co m
No.and Strcet Telephone ` `�Emil AJJ
SECTION 3: DESCRIPTION OF PROPOSED WORIbt(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) O Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': Q! �a
SECTION a: ESTIMATED CONSTRUCTION COSTS
Itcin Estimated Costs: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee:$_ Indicate how fee is determined:
❑Standard City fawn Application Fee
42. rical $ ❑Total Project Cost](item 6)x multiplier x
bing S P QtherFees: S
anical (HVAC) $ - List:
anical (Fire S Total All Fees:S
siun)
Check No. Check Amount: Cash Amount:
Project Cost: S I a l d ❑Paid in Full ❑Outstanding Balance Due:
(�-
SECTION5: CONSTRUCTION SERVICES
5.1 CoP'nstractimi Sup rvisor License(CSL)
License Number Expiration Date
Name of CSL Holder List CSL'rype(see below)
Type - Description
No.and Street -
U UnrestricteJ BuilJin u �to 35,000 cu. It. _
R Restricted I&2 Famil Dwelling
Citylrown,State,ZIP M INfasonry
RC Roofin Covering
WS Window and Sidin
SF Solid Fuel Burning Appliances
1 Insulation
T
elephone Email address D Demolition
d Home Improvement Contractor(HIC)
HIC Registration Number Expiration Mice
ENo.aud
ame or HIC Registrant Name
- Email address
te ZIP Tele hone
SECTION 6:WORKERS,.COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.15L§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 Isivance of the building permit.
Signed Affidavit Attached? Yes ..........0 No...........O
SECTION 7a:OWNER AUTHORIZATION.TO BE.COMPLETED.WHEN'
OWNER'S AGENT OR CONTkk&ORAPPLIES FOR BUILDING PERMIT
I,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:OWNERt OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Otflt� b(T
Pri t(1wncrkw,%ut dzcd Age is amc(Electronic Signature) Date
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)i will no have access to the arbitration
--- -- - P- - - - 6
program or guaranty fund under hLG.L.c. 142A.Other tat arrant information on t elilCYro ram can a oun tT
www mass.cov'oea Information on the Construction Supervisor License can be_round at www.nms�
2. When substantial work is planned,provide the information below:
'rotal floor area(sq. ft.) _ _ ~ ,(including garage, finished basementlattics,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 orcooling system Enclosed Open
1. "Total Project Square Footage"may be,ubstituted tor-rotal Project Cost"
1
CITY OF SALEA MASSAC HLEE M
`y BLnDmDEPARnvw
120 WASFIIPTMMSTRWO3mRODR
1kL(978)745-9393,
PAX(978)7449846
SIAJBERLEYDR1SOt7LL
MAYOR 1JOWASST.PI =
DIMECrUt OF P1MMCMtMM/J1UMDMaMWWC9M
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 coo,S 54; Building Permit g is issued with the
condition that the debris resulting from this work shall be disposed of in a property licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by.
(n me of hauler)
The debris will be disposed of in:
l-.CuCI�G�c)
(name of facility)
(address of acility)
r
Slgnatu4 of applica
Date
a
QTY OF SALEM, MASSACMEM
BLALDING DEPARTMENT 120 WASEHNGTONSTREET,3ft0 FLOOR
TEL. (978)745-9595
F
KIMBERLEY DRIS�LL FAX(978)740-9846
MAYOR THOMAS STAERRE
DIRECTOR OF PUBLICPROPERTYALALDING OQA&ISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT.
Date QL4 )9 I H,
Job Location (o [ e rbcy-4�
''f S� r " c y r
Home Owner Address (D er ye�y l l M P, Q 1 q
Present Mailing Address b +krbe t-+ (� f s n2 , m a n 19 �To
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 INSPECTOR