23 HERBERT ST - BUILDING INSPECTION The Commomcealth of MassaChuselts It
Boaid of Building Regulutiuns :mJ Standards \II-Vll ll'.\III 1
Massachusetts State Building Code. 7S(3 CMR. 7' edition
(, • t tit,
l3uilding hermit ,�pp atus, o C•UnStrtlCL Repair, Rcnosate Or Demolish a R, �,�d lo, a,
One- u Toor J•',ur,ih
T s Section For Official Ilse Only
--7
Building Permit Num r: Date Applied:
Sienature.
131.111dwg Cumnus.wne it Peel r of Buildings Dale
SECTION 1: SITE INFORMA FION
L1 Proxerh .�1dd�reJ�ss�:� --- 1.2 :Y ssessurs "'up
& Parcel Numbers --- - -
__.__ \la :Nunher P:urei Numho
I la Is Ih:s :;n accepted ourrt'. yes nu--- P
1.: Zoning Fnfoemaliu 1.d Property Dimensions:
i
- - --
F:owr ee ui;
lining Du:nr. Pn,pueeJ Use Lut:lrea uq ul
�•` Front Yard —. --_— Side Yards Rear Yaid
! Rryd�rcd Provided Required Provided Rey,r.reJ Pn,udrJ_��
.6 Water Supply: tM.G.L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone' ,MunkP I i al On sne dis w 'sal . aem ❑
Puhlir Private ❑ Check if yes❑ Jf
SECTION 2: PROPERTY OWNERSIIIPr
L�0 w n`rtof Rc rd- - ITV �3 CL���-E'�S�.k•Y!_'l� n'1'b�---
N.un, Print) CJl _- Address for Seniee:
Si n:rm;r _-'_- Telephone
SE PpYCTION 3: DESCRIPTION OF PROPOSED WORKz(check all that u I ) —
- --
—� ---�
�ewC n,ruLn,,n Existing Bui W ing ❑ Owner-Occupied C I Rw reds) teranunls) ❑ ,1JJitn�n ❑
l ,::,:ir,.,n ❑�_ACcessu-v Bldg. ❑ Number ut Unit. L- Other ❑ S way._
I -_ -s
Ff� D:,script�.ur. of P` Pry i)osed- ork':_�ot�5<(LJG`Y Sl`ArZ _�-_`z tr�� - •"ol` ---
st�--a
SECTION J: ESTINI,.TED CONSTRUCTION COSTS
Estimated Costs: -- - -�
Official Use Only
Item
i (Labor and Materials) _
I. Building S 8o0 i t. Building Permit Fee: $_ Indicate hum fee Is detenni lied:
❑ Standard City/Town Application Fee
2. Faecuia cl S
❑ Total Project Cost (Item 0) x multiplier,,,��� ///••• x
3. Plumbing S n. Other Fees: S � �r
4. :Nfech:nicul (HVAC) S List:
5 Mechanical (Fire
S � Total :\II Fees: S -
Suppression)
Check No. Cheek :\mnunc ('.,sh :\nn uuu _- - -
0 Total Project Cost 5 0 Paid :n Full 0 Outstanding Balance Due _-
SECTION 5: CONSTRUCTION SERVICES
S.l Licensed Cunstructimt Supervisor (CSLI
I_iccn.c Nuniher t[s{nr.woni Datc I
Nan0.•of CSL- Holder
Lui CSI_ fs pr i.rr hduw 1
WJress Iv c Descri Neon
C tlucstnca•J u +to 15.(A)0('u. Pt 1
—_ — W! Rc,umcd d 1,YL2 F, ih Dss.lhnC
Unhal Hu��linc l'usaink.il \1'inJ,J S1iliJ I uCI liutwne \L+L enCC Imi.ill.w,-uial UC nuihurn ___�
5.2 Registered Home Improvement Contractor lHIC'1
HIC Company Name or 111C Registrant Name Registration Nuniher
Address
F,opiation Date
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. 9 2506))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to pros ide
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 PERNIIT _
1, , as Owner of the subject property hereby,
authorize n to act on my behalf. in all ni.utels
relative to rn k auth tr zed by i s building r .it application.
Si Ill re Owner Date ------- _��
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
(• , as Owner or Authorized Agent hereby declare
that the statements and information on the fo regoing application are true and accurate. to the best of my knowledge and
behalf.
Print Nane
Signature of Owner or Authorized Agent Date
(Signed under tits 2ams and penalties of perjury)
NOTES: _
I. An Owner who obtains a building permit to do his/her own work or an owner who hires an unregistei ed contras 1,11
(not registered in the Home Improvement Contractor (HIC) Program), will not have access to the arbinallon j
program or guaranty fund under M.G.L. c. I42A. Other important infturnation on the HIC Program .ind
Construction Supervisor Licensing (CSL) can be found in 780 C11R Regulations I IO.R6 and 1 10.125. iespecmdy.
2 When substantial work is planned, provide the information below:
Total flours area(Sq. Ft.I (including garage, finished baeeiner JattlC], decks or poi Chi
Gross living area i Sq. Ft.) Habitable morn count
Numberof toeplaces Number of hedrooms
Number of h.uhiowns Number of hilt/baths ,---------------.. -
hepe Uf heating system --- _ Number of decks/ ptachcs .-------_- ..
Type of cooling system --------
3 "Total Project Square Footage" may be substituted fin"Yogi Project Cost-
_ . ' 'y S CITY OF SALEM
71 .
PUBLIC PROPRERTY
TMENT
DEPAR
.'d 12( A\.I I IN(.,,IN Sl'a Ll-T 4 $.\Illl, \L\'�i.\� �.. ai l l�.l'I
Construction Debris Disposal Affidavit
(icquired liir all demolition and renovation work)
In accordance \\1i the sixth edition of the State Building Code, 780 CIv1R 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
Il1. S 150A.
The debris will be transported by:
manic of hauler)
I lie debris will be disposed of in
ptmne ut lacility)
luddress u(1'acility)
1
_natm'c of permit applicant
C
._ date -----
CITY OF S.0 EM
PUBLIC PROPERTY
DEPARTMENT
K1411�cv ivwvv.
130 WA"NG ON S AM 0 sAuEK% ASUOmrt-wM 01970
7e1:97t-74S-9S"9 FAs 97L74&9M
HOMEOWNER LICENSE EXEMPTION
Please Print
Date
Job Location Z EJ27T ' S
Home Owner ss _Addre G I M
Home Owner Telephone -1-6
Present Mailing Address
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.
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on
which them 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 ity of Salem
Building Department minimum inspection procedur and requ• is and that he/she
will comply with said procedures and en .
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code