10 HERBERT ST - BUILDING INSPECTION (2) 9A
t' The Commonwealth of Massachusetts
�V \� Board of Building o Regulations and Standards CITY SA EMF s Massachusetts State Building Code, 780 CMR
Revised Mar 201l
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Ap lied: !'
T')L9
Building Official(Print Name) ' gn• re D e
SECTION 1: SITE I ORMATION
1.1 Property Address: 1.2 Assessors Map& creel Numbers
io fErrrs�- s% SFYL Rt Ate /12A-;-3s Gor -z97
1.1 a Is this an accepted street?yes no Map Number MSA Z/bo4 Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Z a snn :fie. 31
Zoning District Proposed Use Lot Area(sq n) U Frontage(11)
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,-§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone? J
Public t� Private❑ Check ifyes� Municipal(d On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP`
2.1 wner'of Record:
Name(Print) City,State,ZIP
3 3; '/fir- 3�f 7767 yLi"Vp x a-e
No.and Street Telephone EmaiLAddress
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) -
New Construction ❑ 1 Existing Building El, Owner-Occupied ❑ Repairs(s) Aft eration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': 1t4z0y1At& p G �—o iT
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)- ..
I. Building $ S-p p , oo 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(.Item 6)x multiplier x -
3. Plumbing S 2. Other Fees: $
4. Mechanical (HVAC) $ List:.`
5. Mechanical (Fire $
Suppression) Total All Fees: $
6.Total Project Cost: $ pp, d Check No. Check Amount: `- Cash Amount:
0 Paid in Full 0 Outstanding Balance Due:
•mil y
SECTION 5: CONSTRUCTION SERVICES -
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu. ft.)
R Restricted 1&2 Family Dwelling
City/Town.State.ZIP M Masonry
RC Roofing Covering
WS Window and Sidin
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
- City/Town,State,ZIP Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE.AFFIDAVIT(M.G.L.c.:152. § 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 .......... ❑ No...........
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,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 Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest tinder the pains and penalties of perjury that all of the information
contained in this application is true�ute to the best of my,knowledge and understanding.
. dCSI/✓ GFYNr(� (o � �y
Print Owners or Authorized Agent's Name(Electronic Signature) Dale
NOTES:
I. 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 not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.aov/dps
2. When substantial work is planned,provide the information below:
Total 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
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF Sm.Em
PUBLIC PROPERTY
DEPARTMENT
1 b i'UIpII.UN arfYr•tAuy MAYAp&MM 01910
TYL f7814-91"•F.uL 97a.74&9ey
HOMEOWNER LICENSE EXE.1 "JON
Plsw irriet
Data 113
lob[acadoe
HomeOwnwAddeesr / � s�B/ 1��T gT , 4� �c1, iGlf� 011'70
Home Owner Telephone -7 7 4--Z—
Presed Mailing Address
The current exemption of"'Homeowners"was extended to include ownaroccupied
dwellings of two Units of teas and to allow such homeowners to eagags m individual for
hire who does not poaaeas a Iicenso provided that the owner acts as superviaw.
DEFM=ON OF HONEOWNER
Person(s) who owns a parcel o[tand oa which halshs resides or Intends to resider on
which than is, or is intended to ba,a one or two Ilrmily dwelling, attached or detached
structures accessory to such use and/or (arm atruetures. A parson who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner'shall submit to the Building Oillcial, on a form acceptable to the Building
Official, that he/she be responsible for all such wort performed under the Building
Permit
The undersigned "homeowner"assumes responsibility for compliance with the State
Building Coda and other applicable by-laws and regulations.
The undersigned "homeowner'certifies that hdshe understands the City of Salem
Building Department minimum inspection procedures and requirements and that hdshe
Will comply with said procedures and requirements,
HOMEOWNERS SiGNATLIU
.APPROVAL OF BUILDING DiSPECTOR
See other side for state cafe
CITY OF SM.&M, AUSACHUSETTS
BC mvia, DEP.im0sT
1'01V.UHLVGT0N STRBSC, Y"Rcict
lit. �97� 74S.9S9!
U\�ERLfiY DRLSCOLL FAX(973) 7449&W
MAY01 rRomm ST.PmXAS
Dixwrct OP Pl BLIC PROPItTY/3t:MDLYC CowmissroV Et
Construction Debris Disposal Affidavit
(required for all dem01id0n and renovation work)
In accordance with the sixth edition of the State Building Code, 790 CMR section 111.J
Debris, and the provisions of MOL 0 40, S 34;
Building Permit a is issued with the condition that the debris resulting from
this work shad be disposed of in s property licemed waste disposal facility as defined by VIOL c
111. S I JOA.
The debris will be transpartcd by:
i 76( F-
(mina Of hauler)
The debris will be disposed of in :
(name or hctlily)
3darm or ri niny)
t
u n�mra orgermtt ip t• At
J�ta