10 HORTON ST - BUILDING INSPECTION 7, - ' The Conunonwealth of Massachusetts
;'iI Board Of Building Regulations and Standards CITY OF
5 Massachusetts State Building Code, 780 CMR S \LGM
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Funnily Divelhi g
This Section For Official Use Only
LBuildingPermitber: Dat pp ied:intNano) Signs tcSECTION is SITE INFORMATION
s: 1.2 Assessors Nlap& Parcel Numbers
> sT
I.1 a Is this an accepted street?yes_ no Map Number Parcel Number _
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed the Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c. J0,§Sq) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Lone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
Owner'of Record:
M te(Pri ) Uty,St ZIP
/2ffo 2To ra ��2/
Nu.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Own ccupied ❑ I Repairs(s) ❑ I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ umber of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIDIATED CONSTRUCTION COSTS
item Estimated Costs: Official Use Only
I Labor and..\Iarerialsl Y
1. Building S I. Building Permit Fee: S Indicate how fee is determined:
'. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost(Item 6)x multiplier —_ x
3. Plumbing S �, Other Fees: S
J. .\Icch:micul C)
S. .\Icchan1, 1Fire ---------
tiu trcssion) S Total .\II Fees:S ------._..-.
Check No. _Check Amount: --Cash :\mount.
6. Total Project Cost S -- -
�p no ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES r
5.1 Construction Supervisor License(CSL)
Livensc Nunthcr — --- Gcpiration D;tle
N;une ol'l'SI. Ilnlder --- ---------�---
Lisl CSL l)pe Isec hclotvl
1'cpe Description
(I I Inrestricted 1 Buildings ti to 35,000 cu. tl.)
_ __ —.._... It Restricted M2 Famil • Doellin
Cilyi rua n,State,ZIP Nt Nlasonry
RC Roolin g Covering
INS Window and Siding
SF Solid Fuel Ilurning Appliances
I I is3dulinn
'talc hone [:mail address D I Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Registration Number Expiration Date
I IIC Company Name or I IIC Registrant Name
No.and Street Email address
City/Town.State,ZIP 'rele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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 .......... ❑ 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.
Print Owner's Nunte(Electronic Signature) Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering Iny name below, I hereby attest under the pains and penalties of perjury that all of the information
containe ' this application is true and accurate to the best of my knowledge and understanding.
Print Ot�r Authorized Agent's Name(Electronic Signature) Da e
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 r o have access to the arbitration
program or guaranty fund under NEG.L.c. 1 2A.Other important information on the HIC Program can be found at
ncl s • ,t. n.l Information on the Construction Supervisor License can be found at tl ll t.nyls g ) 'dii„
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.l (including garage, finished basement'attics,decks or porch)
Gross living area(sq. tt.) __._. _ Habitable room count
Number of fireplaces.__ 'Number of bedrooms
Nunlher of bathrooms - --- Number of half halhs -- - _
'f)pc of heating s)slcnl Number of decks, porches -
rlpeofpWllilgS�itenl ..... . Enclosed _ --. _ Open
3. "Fatal Project Square FooiagC"ntay he Substituted fix"1'0htl Project Cost'
CITY OF S.U.E.Nl, LLNLASSACHUSETCS
BLMDLNG DEPARTNONT
120 W.1.mmTON STREET, 3i0 FLOOR
TEL (978) 745-9595
F.kx(978) 740-9846
Kl.N®ERLSY DRISCOLL
MAYOR THoum ST.PtPata
DIRECSOR OF PLBLtc PROPERTY/BLUMING CMDUSSIONER
Construction Debris Disposal 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 c 40, S 54;
Building Permit tl 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
l 11. S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
4tinature of permit app icant
�2a1Z l (/
Nile
LArrvif,6R
CITY OF Sm-E.m
PUBLIC PROPERTY
DEPARTO ENT
s„u..%v n.su>rL
ru.•&US-9Nt •F.qx 178-7469a4
HOMEOWNER LICLNSE EXEINMION
Pfew Frye
Dap_4 . 4
Job Location l rs A'Z� 2T ap
Home Owner Addreas lb o RToN ST
Home Owner Telephone G q-s - o Q
Prea d Mailing Address /g yv f?Tn rl C : SIB Lem
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or leas 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
Persons) who owns a pared 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[wilding OQlcial,on a form acceptable to the Building
Officiak that he/she be responsible for all such work performed under the Building
Permit
The undersigned "homeowner"assumes responsibility for compliance with the Stag
Building Code and other applicable by-lawn 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 \'X:5
APPROVAL OF BUILDING CISPECTOR
See other side for state code
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