3 HERSEY ST - BUILDING INSPECTION r �
The CommomvealthofMassachusetINSPECTIONAL SE ICFt TYOF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 C5 M�R 2 T Rg1ted blor 2011
_(� Building Permit Application To Construct, Repair, RenovaaUUte Or emo tsh a
1 t One-or Two-Family Dwelling
,� This Section For Official Use Onl
t Building Permit Number: Dattij —' d:
w
I (� Building Official(Print Name). ignature Dat
SEC l'ION'1:SITE INFORtNIAT14m
i
_1r(1 I,1 Property Address: 1. Assessors MapJr Parcel Numbers
I.1 a Is this an acce ted street?yes_ no Map Number Parcel Number
citing Information: i Property Dimensions:
Lun'ng District Proposed Use - Lot Area(sq R) Frontage(It)
1/d Building Setbacks(B)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.61Vnter Supply:(M.G.L c.d0,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
( Public❑ Private❑ Check if es❑
SECTION2: PROPERTY OWNERSHIP!
2.1 Owners of Record:
i i5o �5 , t:t�l�l,CN �Aueo NA�
( tT'Ime(Print) City,State,ZIP
y No.and Street Telephone Email Address
j SECTION 3:DESCRIPTAOIN OF PROPOSED ORW(check all that apply)
' New Construction❑ Existing Building Owner-Oy
Repairs(s) ❑ Alteration(s) Addition
p
Demolition ❑ Accessory Bldg.❑ Numbe Other ❑'an Specify:
i Brief Description of Proposed Work': r1 OV N `
v bL — , d _
_ L I l
' SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Ofllcirl Use Only
Labor and Materials
• I. Building S � O i. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2., Electrical S / ❑Total Project Cost'(Item 6)x multiplier x
} plumbing S U P Qther Fees: S
q.Mech nical (FIVAC) S / List:
' 5.Mechanical (Fire S 'total All Fees:S
Suppression)
Check No._Check Amount: Cash Amount:_
6.Total Project Cu t: $ 1 t)p ❑ Paid in Full ❑Outstanding Balance Due:
mlaIL_jj�V q( z
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
f License Number Expiration Date
Name of CSL Holder
' List CSL'fype(see below)
No.and Street Type - Description
i U Unrestricted Duildin tip-to 35,000 cu. It.)
1 R Restricted I&2 F;unil Dwelling
t C ityfrown,State,ZIP N Masonry
RC Roofing Covering ,
WS WindmvandSidin
SF Solid Fuel Burning Appliances
1 Insulation r
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
•� MC Company Name or IIIC Registrant Name
I No.and Street Email address
d
City/Town, State ZIP Tele hone
,
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
r
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes..........13 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
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:OWNEW 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 it du .ppli ation is true and accurate to the best of my knowledge and understanding.
Pr r r uthorized Agent's Name(Electronic Signature) ate
NOTES:
1. A n 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 NI.G.L.c. 142A.Other important information on the HIC Program can be found at
www.nrass.t:ov:'out Information on the Construction Supervisor License can be found at www.nias� .
2. When substantial work is planned,provide the information below:
Total tloor area(sq. R.) 'r (including garage, finished basementlattics,decks or porch)
Gross living area(sq. R.) 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 ofcooling system Enclosed Open
3. `"total Project Square Footage"may be substituted for"'rot:d Project Cost'
QT'Y OF SALE M, MASSAa-IIJSE 7'TS
1 BUILDING DEFARTMENT
120 WASHNGTONSIREET,3ADFLOOR
ThL.(978)745-9595
KDaERLEYDRISODLL FAX(978)740-9846
MAYOR THOMAS STYIERRE
DIRECTOR OF FUBLic PROFERTy/BUIIAING o[)N&SSIONER
Construction Debris Disposa/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 00, S 54, Building Permit It z is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
I,Pn Cal U
(name of habler)
The debris will be disposed of in:
(name of facility)
(address of facility)
IS Anatur4ofap0plicant
Date
i
L
QTY OF SALEM, MASSACHUSETTS
BUILDING DEPARTMENT
miet ' Ir`'I 120 WASI—IINGTON STREET,3"DFLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KIIvIBERLEY DRISCOLL
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMNIISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date
Job Location 3 Sca,g C)t4Otc>
—�
Home Owner Address-3 1 " Bey S* �c �.�., kfA C3UR,�
Present Mailing Address 3 kAAA� 8X_
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