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13 1-2 HERSEY ST - BUILDING INSPECTION (2) t Y - 1 q 1otT IVEO hhe ConunomvealtERVOS h of Nlassachusetts INSPECTION CITY OF Board of Building Regulations and Standards e Oil I' Massachusetts State Building Code, 780 CNIR 1114 3 1Zeiis .11ur?O/I Building Permit Application To Construct, Repair, Renovate Or Demolish a Orte-or Tivo-Family Dwelling This Section For Official Use Only Buildin, Permit Number: Date Applied: Building Otticial(Print Name) Signature. Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Nlap&Parcel Numbers - L5 5"EZ 57— I.la Is this an ncce fed street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Lot Frontu a Zoning District Proposed Use 9 It) g (11 ) 1.5 Building Setbacks 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? Municipal❑ On site disposal system ❑ Public❑ Private❑ Check if es❑ SECTION 2: PROPERTY OWNERSHIP!` �vnA97-D/Nr Record: C OT/-= `J f�-Ll--r�L 1K�- [➢ ( `z 2 c`7 �me(Prinl) City,Slate,ZIP /6 rA-o 5 i $7S'-7V11-16 (, No. and Street Telephone Iniail Address SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing Building❑ Owner Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: L"I Brief Description of Proposed Work-,: /�s7/�tt /tJ/ tr' tZPvrr 5/{/NI5G�5 alC/ 0c;7-: -t /J/S/�6Sr' �7r ocD 5/4/NSG/m S SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item Labor and Materials) - 1. Building > I. Building Permit Fee:3 Indicate how fee is detennined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x 3, Plumbing 'S 2. Other Fees: S � I. %lech;utird (HVAC) S List: 5. Mechanical (Fire 5 Total Ali Fees: S-S- /Sup ression) Check No. Clieck Amount: Cosh Amount:_ G. Tutai Project Oust: a Cl Paid in Full ❑Outstanding Balance Due: Mfan L-I✓(, -r b k-\. o , Lk 1 j 0 me do ot'ri/19� r ` " SECTION 5: CONSTRUCTION SERVICES 5.1 Coty!ruction Supervisor License(CSL) R�1 [(IUS Licensc Number Expiration Date no of CSL Holder List CSL'fype(see below) Type Description No. and Street U Unrestricted(Buildings tip to 35,000 cu. It.) R Restricted l&2 Family Dwelling Cityfrown,State,ZIP ml Nfasonry RC Rooting Coverin WS Window and Siding SF Solid Fuel Burning Appliances 1 Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Dune HiC Comp:ny Name or HIC Regislrmn Name No. and Street Email address $ City/Town,State ZIP Tcle hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I.c. IS2.§ 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 ..........0 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 Owncr's N:mre(Electronic Signature) 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 contained this a lication is true and accur to the best of my knowledge and understanding. -9 � J IJ71J[FJG J 00f-7= �'—3-.10/'/ Print Owners or Autlturizc gcnt's;lame(Electronic Signature) Date 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 Lint have access to the arbitration program or guaranty fund under M.G.L.c. 1 a2A.Other important information on the HIC Program can be found at wwcv.mass.cov:coca Information on the Construction Supervisor License can be(found at svww.mass.cov'dp5 2. When substantial work is planned,provide the information below: Total floor area(sq:R.) (including garage, finished bascment/attics,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 onccating system Number of decks/porches Typc of cooling system Enclosed Open_ 1. ••NMI Project Square Footage"may be.substinded for"fatal Project Coal" I r CITY OF SALEM, MASSACI IUSETTS BUILDING DEPARTMENT 120WASHINGTON STREET,3 FLOOR �m � TEL. (978) 745-9595 FAx(978) 740-9846 KINIBERLEY DRISCOLL MAYOR THOMAS STTIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING CONWIISSIONER HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: Date Job Location 13 1jj /4 raSr�>` 5 7- _-5 aL4:F m M y1- Home Owner Address /& k9rFA-0 OJT S/L�/ � ff►L - Present Mailing Address & PF'At7 5 / 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 1, a` CITY OF S'ULE',f) ;ti xs&S CHUSETTS ©UILOLNG DEP:IRntE.rT j 130 W.ISHCYGTON STRFST, Jw FLOOR -•..� "-, TRL (978) 743-9595 F-Ax(978) 7-10-984d luNtBeRLEY ntuscott NLAYOR -n-IOSLAS ST.PI^cRRB DIRECTOR OF PUBLIC PROPERTY/B':'LDLYG CONNISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition Of the State Building Code, 730 CMR section l l 1.5 Debris, mid die provisions of NIGL c 40, S 54; Building Permit tk is issued with the condition that the debris resulting from this work shall be l l 1, S ISOA. disposed of in a properly licensed waste disposal facility as defined by tNIGL c The debris will be transported by: y y A1C2�15.nc day (name ufhauler) The debris will be disposed of in (name of f�cdity) — — ~--(addressot'ric lity) signature(jeep, mit applicant