9 HORTON ST - BUILDING INSPECTION (4) .. R
The Commonwealth of Massachusetts
1 4 , Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7'"edition OF SALF:M� xrvisrr/Jwnurn•
Building Permit Application To Construct, Repair, Renovate Or Demolish a
I One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Nu r: Date Applied: 7 2 0 ! v
Bt)il i issi /Inspector of Buildings (Yale
SECTION 1: SITE INFORMATION
1.1 9 /peo Add� _7 rfss: 6f 1.2 Assessors Map& Parcel Numbers
I.I a Is this an accepted street?yes no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zo ning District Proposed Use La Am(sq 11) Fromage(It)
1.5 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: 1.3 Sewsge Disposal System:
Zone: Outside Flood Zone?
Public❑ Private❑ — Check if es❑ Municipal O On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
t
2 Is r ofRecod:�
ume(Print) Add or Service:
� 2CP - -7 5Z/- 1,73
Signature -Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Nu nits_ I Other Cl Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 011lclal Use Only
Labor and Materials
1. Building S I. Building Permit Fee:f Indicate how fee is determined-
2. Electrical f ❑Standard City/Town Application Fee
❑Total Project Cosl'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) f List:
S. Mechanical (Fire S
Suppression) Total AI)Fees:f C4a&
Check No. Check Amount: Cash Amount:
6. Total Protect Cost: S D ❑Paid in Full ❑Outstanding Balance Due:
r
SECTIONS: CONSTRUCTION SERVICES f
5.1 Licensed Construction Supervbor(CSL)
License Number ENpintlon WIC
Name of C'SI.-I IulJer List CSL-type(see below)
(' Description
:\JJrea U (Inrestricted u to 35.000 Cu.Ft.
R Restricted IR2 Family Dwellin
Signature M M Only
RC Rnide 31 Knotting C'overin
I clephone 7DResidential
Window and Sidin
Solid Fuel Bumin Appliance Installation
Demolition5.2 Registered Home Improvement Contractor(HIC)I IIC Company Name or HIC Registrant Nameegistration Number
Address Expiration Date
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. IS2.y 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 ..........0 No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I 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.
siggLauntorOwner Dote
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
' as Owner or Authorized Agent hereby declare
that the statement and information on the foregoing 4pplication are true and accurate,to the best of my knowledge and
t ame '=fzL-�
Signature ol'Owner or uthorized Agent Date
Si under the ins and nalties of 'u
NOTES:
FAn 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_W 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 790 CMR Regulations I IO.R6 and I IO.RS, respectively.
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
). "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
INS IN I IT # SAI I III,
I),8-74i.9;95 # 1:X.\: 9,8_174_ 9 41,
Construction Debi-is Disposal Affidavit
(rCLItthed lbr all demolition and renovation work)
in accordance with the sixth edition of the State Building Code, 780 CNlR section I 11.5
Debris, and the provisions ofMGL c 40, S 54;
Building Permit ft-- - is issued with the condition that the debt-is resulting front
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
t 11. S 150A.
The debris will be transported by:
XJO/V(�_
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
slenatulcof J)':mlit applicant
date
CITY OF SALE.N1
PUBLIC PROPERTY
DEPAM6 LENT
KJ fOkJl.i11 O-...'•v.
.MA1Oa 130 WADWiGr M 271Far•SAUK NwaAOR'scrn o19'0
T1i V..LT+SAS"• F.ut 9'6.740-980
HOMEOWNER LICENSE EXE.MMON
Please Print
Date / /
Job Location 0 D/-ko 0 �� S Ql fYl
Home Owner Address
Home Owner Telephone -)ff 7 V / / 73 T
Present Mailing Address of vYt -Ae
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.
DEFINMON 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 fort 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.
HOMEOWNERS SIGNATURE
.APPROVAL OF BUILDING INSPECTOR
See other side for state code