18 HERSEY ST - BUILDING INSPECTION ,
The Commonwealth of Massachusetts
i Board of Building Regulations and Standards CITY
!7 ) Massachusetts State Building Code, 780 CMR, T"edition OF SALEM
Revised Junuury
Building Permit Application To Construct,Repair, Renovate Or Demolish a 1, ;ooR
n One-or T t o-Fumdv Dwelling
1 1 This tion For Official Use Only
Building Permit Number: Date Applied: (�� (7
Signature:
Buildin Commissione 1 of Buildings Date
SECTION I:SITE INFORMATION
1.1 Property Address. 1.2 Assessors Map& Parcel Numbers
1.1 a Is this an accepted street?yes—x— no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(11)
I.5 Building Setbacks(R)
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?
Public Private❑ Check if yesCI Municipal Won site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ow_ nerto 0, :
Name
CUI2IN�.l i C�uF �
ame(P' Address for Service: '
Aign lure Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': _
%JC--1VZX-
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 011iciai Use Only
Labor and Materials
1. Building S I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List:
F6.uTotal
Mechanical (Fire S
oppression) Total All Fees:S
Check No._Check Amount: Cash Amount:_
Project Cost: S ❑paid in Full 0 Outstanding Balance Due:
I
1
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number I:xpirauon Date
Name of CSL-I lolder List CSL Type(see below)
r.PC Description
Address U I.Inrestrict T(up to 35.000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC Residential Roufin Coverin
roephont WS Residenial Window and Sidin
SF Residential Solid Fuel Burning Avoliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
IIIC Company Name or IIIC Registrant Name Registration Number
Address Expiration Date
Signature 'relephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 2SC(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...........O
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.
SismaturcofOwner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
I � ii , �. QUA as Owner or Authorized Agent hereby declare
that the scat ents and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
nt N
ature of Mor&thorlF=2g�cnt Date
(Sianed under the pains and penalties of 'u
NOTES:
I. An Owner who obtains a building permit to Jo his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will no have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I IO.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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 SALEM
; i
PUBLIC PROPRERTY
DEPARTMENT
I'.R: F111 "MIV '1I
\I ,1„N 1:c R•.tM It\L., V 51'Nkl'i 1�.11I\I,\L\KU 111 4 1,`.I'I -
I'FI Vlt-%J4')iIS �1 \'t:Nl/•1JS'I:IJA
Construction Debris Disposal Al idavit
(required ter all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 11 I.S
Debris,and the provisions of MGL c 40,S 54;
Building Permit 0 is issued with the condition that the debris resulting fromthis
this work shall be disposed of in a properly Licensed waste disposal facility as defined by MGL c
I l 1. S I30A.
The debris will be trunsportcd by:
foams of hauler)
The debris will be
disposed of in
e 1�gyli�
(Ila"of rat;ltty
t address of 11x I lily)
l +I�uature of Iwrmil appli¢aM
��ic. a31 �oio
date
L bn.dl,:w
CITY OF S.ULE.NI
PUBLIC PROPERTY
DEPARTMENT
VAVOS 130 W.QuxGTon 9711ear•Sued NAsL4cmsar7S ot9V
TIM rl-715-9S" 978.74&9646
HOMEOWNER LICENSE EXE.MPTION
Please "I
Dan 3 /D
Job Location rA S�
Home Owner Address oVr��'
Home Owner Telephone 36 y4
Present Mailing Address
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or lean and to allow such homeowners to engage an individual for
hire who.does not possess a license,provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on
which there it, 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 construct@ 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 City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements. -
H04fE0WYERS SIGYAILRE �� �G
APPROVAL OF BUILDING INSPECTOR
See other side for state code