18 HORTON ST - BUILDING INSPECTION 0 o
The Commonwealth of Massachusetts CITY OF EM
WBoard of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR T' ( �ra
Building Permit Application To Construct,Repair,Renovate Or DeM%9 d Vl
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Pr e!rty Address:
C 1�.._"Et4 on Stke� `j(Jem M A om a Assessors Map&Parcel Numbers
L is Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 wner'of Record:
_c L Sale M A D l 97
` ame(Print) City,State,z
19 l-byTtuv, S+reP (122)71-g -Ls20 '!
No.and Street Telephone E ail Addres
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ElAddition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
n_Rea;( ha.Ct2y anoY vojc
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ �'
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire Suppression)
$ Total All Fees:$
-_..�
-check No. Check Amount: Cash Amount:
6.Total Project st: $ i w o. 0 P)V in Full 0 Outstanding Balance Due;
t
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
a� Name of CSL Holder
'' ` ' t Gl i 3qu; List CSL Type(see below)
r No.and Street rDDemolition
Description
J ' r Y_ f
y �� ���! stricted Buildin s u to 35,000 cu.ft.
Ctty/fown,State,ZIP icted IkI Famil ri—mn
In Co-
wsow and Sid;—
SF Fuel Burning Appliances
ationTele hone Email address olition5.2 Registered Home Improvement Contractor(HIC)
strntion Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
Ci /Town State,ZIP Telephone
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
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No...........❑
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 Name(Electronic Signature) Date
SECTION 7b:OWNER'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 in this application is true and accurate to the best of my knowledge and understanding.
/X\ Vs�rl r?m CYt It hQ� LAM/ R r.�.d
Print Owner's or Aumonzed Agent's Name(Electronic Signature) ate
NOTES:
1. 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 not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
wvww.mass.gov/oca Information on the Construction Supervisor License can be found at www mass goy v/dns
2. When substantial work is planned,provide the information below:
Total floor 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, MASSACHUSETTS
f< III BUILDING DEPARTMENT
120 WASHING'CON STREET;3"FLOOR
TEL. (978) 745-9595
FAx(978) 740-9846
KINIBERLEY DRISCOLL
MAYOR THomAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date q/8 12,o1 \
Job Location p p o
IR �-�- r�" v\ tree Sod ean M A a 19 21)
Home Owner Address ig 14-byi"avv 51t� A,I_eer. SP M�2�
Present Mailing Address is H-yy m 5tfeet 7 sajeyA M � n f q2o
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 C� - / r 4L
APPROVAL OF BUILDING INSPECTOR
CITY OF SALEM, MASSACHUSEM
BUILDING DEPARTMENT
120 WASHINGTON STREET,3tD FLOOR
venx' TEL. (978) 745-9595
F
KIMBERLEY DRISCOLS, FAX(978) 740-9846
MAYOR THomAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERriALULDING COMMISSIONER
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 c40, S 54; Building Permit # 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:
1v, �lDnse ��ea�.o�ts an� 17�sIPo5od / G+0Vk?LA1AAA o2-190
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
Date
z
FULLY INSURED ' www.inhousedisposal.com
I I �
e L E A N 0 0 T S A N e 0 1 S P 0 S A L
P.B.Box 528 781.568.9158 Stoneham,Bill 02180
INVOICE / COD
ORDERED BY'
DATE: :j l- 3- I
BILL TO:
J
TENANT
PHONE:
TEL# HOME:
WORK: ORDER TAKEN BY. c/f rc
CELL: G-1- M-11"t' TECHNICIAN: F cnh
NEW CUSTOMER: 3 YES ❑ NO
SERVICE REQUESTED / PROBLEM REPORTED: JOB COST
``
RENTAL:
I✓Cr�� Y�"I IG ! t .r_K'1� iIC.. 1-/lJ'!"
j 4 c ehS LABOR:
WORK ORDERED / ACTION TAKEN / -
TECH NOTES: DISPOSAL: S
EQUIPMENT:
i
TON OVERAGE:
I AUTHORIZE THE WORK AND WILL PAY IN FULL BY:
❑ CA�H ❑ CHECK # xdcREDIT ,N C TOTAL: 3�S
THANK YOU!
WE ARE NOT RESPONSIBLE FOR DRIVEWAY DAMAGE.