22 HOWARD ST - BUILDING INSPECTION (2) Y �
f lZi. The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
U n SALF'M Massachu s S to Building Code, 780 C'MR, 7 edition
Rrvisri�rr/Jonnurs•
Building Permi pplicali n To Constrisq.,Repair. Renovate Or Demolish a /. -1NAY
On -or Twu-F Uy Dwelling
This S on For Official Use Only
Building Permit Number: Date Applied: F-VI 0
Signature: View r7
Huilding C mini nspeclor of Buildings Date —�
SECTION I:SITE INFORMATION
1.1 Properry ddress, / 7 1.2 Assessors Map A Parcel Numbers
L Z D a.) r3,
I.to Is this an accepted street?yes no Map N�ber Parcel Number
IJ Zoning Information: L4 Property Dimensions:
Zoning District Proposed Use Lot Arco(sq 11) Frontage(I))
I.s Building Setbacks(n)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
I.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Dbposol System:
Public D Private O Zone: _ Outside Flood Zone? Municipal D On site disposals stem D
Check if aD y
SECTION2: PROPERTY OWNERSHIP'
2.1 errpf Record
KdZrip T Ord��r7 L Z `�ts r�l Y cS
Nome n // Address for Service:
�2in�o � A- r 2�1� �1)�
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check oil that apply)
- - New Construction O Existing Building D Owner-Occupied Repairs(s) D Alleration(s) O Addition D
Demolition ❑ Accessory Bldg.D Number of Units Other D Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials )'
L Building S I. Building Permit Fee:S Indicate how lee is determined:
J4.
. Electrical S ❑Standard City/Town Application Fee
D Total Project Cost'(Item 6)x multiplier x
. Plumbing S 2. Other Fen: S
Mechanical (FIVAC) SList:
. Mechanical (FireSu ression Total All Fees:S
Check No. Check Amount: Cash Amount:
Total Project Cost: S ,S�(� ❑Paid in Full 0 Outstanding Balance Due:
=1,,ILkr
CTION S: CONSTRUCTION SERVICES
or(CSL)
License Number Expiration Owe
ListC'SL fype(see below)
f Deseri ion
U I Unrestricted to 75.000 Cu. Ft.
R Restricted Ia2 Famil D%tilin
Sipwture M masonev,only
RC Res':1ial Roolin Coverin
Telephone WS Raidentiof Window and Sidin
7DRcsitknIiW
Sulld Fuel Bumin A lianc a Installation
Demolition
5.2 Registered Home Improvement Contractor(HIC)
IIICCompanyNameorIIICRegistrantNameegistratim Number
Address Expiration Date
Signature 'felephum
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.C.L a 152 f 2!C(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? Yea ..........O No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
NER'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.
simmure of owner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
1 ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are We and accurate,to the best of my knowledge and
behalf.
Print Name
Signatore of Owner or Authorized Agent Date
70wner
der the sins and nahier ofPerjury)
NOTES:
wner who obtains a building permit to do hia/her own work,or an owner who hires an unregistered contractor
gistered in the Home Improvement Contractor(HIC)Program),will ad have access to the arbitration
m or guaranty fond under M.G.L.c. IJ2A.Other important information on the HIC Program and
ruction Supervisor Licensing(CSL)can be found in 790 CMR Regulations I IO.R6 and I WAS,respectively.
substantial work is planned,provide the information below:
area(Sq. Ft.) (including garage, finished basementtattics,decks or porch)
g area(Sq.Ft.) Habitable room count
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 he substituted for"Total Project Cost"
1 l
CITY OF SAI.E.N1
PUBLIC PROPERTY
DEPARTMENT
ILIfOFyiy ev".vY 1
VAroa 13e WA94NGTC M STMW•IMAK NAssAnR'scrrs 01970
TFt 978•7154S"• FAX.975-740-990
HOMEOWNER LICENSE EXEMPTION
Please Pritt
Date
Job Location 2-2- 11a ,)RrW 57�.
Home Owner Address 2-2-
Home Owner Telephone 9172 .S SLR /,7:5L7
Present Mailing Address zz //06,1a.- Jt-
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 interds to reside, on
which there is, or is intended to be, a one or two family dwelling, attached or detached.
strictures 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 OSicial, 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.
HOMEOWNERS SIGNATURE
.APPROVAL OF BUILDING RNSPECTOR
See other side for state code
i
y
CITY OF SALLM
PUBLIC PROPRERTY
DEPARTMENT
't.'a- O.S 7b
Construction Debris Disposal Affidavit
(required lirr all demolition and renovation work)
In accurdancc with the sixth edition of the State Building Code, 780 CNlR section 1 1 L5
Dcbris, and the provisions of b1GL c 40, S 54;
Building Permit # is issued with the condition that the debris resultins from
this work shall he disposed of in a pruperly licensed waste disposal I'acility as defined by MGL c
111. S 150A.
The debris will he transported by:
/f��ILTIr ,1' l&,t G--7_I +'G--
Iname of hauler)
The debris will be disposed of in
p4 LLLo J 4YLL� GA��r✓7✓
(nainr ul Iacility)
Da trrra /ZZ*
(ad(fress ul Facility)
HLIIaIU of( not .tpphcaut
19 ,;2 �
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