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32 IRVING ST - BUILDING INSPECTION I The ('onununwealth of Massachusetts i IOR Bomd of Building Regulations and Standards Ml'NI/'ll'.\I.fll Massachusetts State Building Code, 780 C'MR. 7°' edition I ISE v Buildin�� Permit Application To C'unstrucL Repair. RC110\'ate Or Demolish a Kr1 i,rJ.l:utu,u, r Ohre- or- Tit o-Family Dwelling / _"(6 This Section For Official Use Only Building Permit Nm deer: _ Date Applied: OT-- Buildiug Conunisswne Iropeeurt of Bui Wings Date —� SECTION 1: SITE INFORMATION __-- f L1 Property Address: S r 1.2 \ssessors Map & Parcel'Nmubers I.la Is iris an actep!e.d snort'? ycs.0( no_ .. Map Numher P:urel Nuulher 1.3 Zoning Information: 1.4 Property Dirneusioos: Zoning Di strict Proposed Use Lot Area(sq ft) Frontage (it) --- 1.5 Building Setbacks (fq r From Yard Side Yards Rem Ya,d ! Re quired Provided Required Provided Requited 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? Municipal ❑ Oil site disposal system ❑ Public ❑ Private❑ Check if yes❑ P SECTION 2: PROPERTY OWNERSHIP[ 2.1 wnerr of ei:7d: Name(Print) Address for Service: Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction ❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ j Demolition ❑ Accessory Bldg. ❑ Number of Units__-__ 1 Other ❑ Spcciiy_ —� B'ief Descnptien of Proposed 'Wurk': --- R�Jn.ot/'+/_�Q � CI�jS{ArsPir*76� Liri"1i �_ SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only fl_abor and Materials) I. Building S 1. Building Permit Fee: S Indicate how fee is Jerernunrd: � ❑ Standard City/Town Application Fee 2. Electrical $ ❑ Total Project Costa (Item 6) x multiplier x 3. Plumbing S 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire S Suppression) Total All Fees: S Check No. Check Amount: ("ash Amount � j b. Total Project Cost: S ❑ Paid in Full ❑ Outstanding Balance . O t7 SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor (CSI.) License Ntunher P.spiruion Dale Nana of CSL- IIoIJer List CSI. Tvpe (see hclow) 1Jdress Type De' 1(ion C Unrestricted lu i to . .uUO Cu. Fl.l R Restricted I. ' anal\ D��rllme Signature M �1:uunry tiv -- RC Resi uiul Rooting Cosenile Telephone AVS R .idclinal Wind'),,and Snline _ SF 2esidenn'll Solid Fuel liurmne \ p ih:mee In.lailawm� D Residential Demolition 5.2 Registered Home Improvement Contractor (11IC) HIC Company Name or HIC Registrant Name Registration Numhe Address Expiration Date Signature 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 prow ide 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 1, , as Owner of the subject property hereby authorize to act on my behalf, in Lill minters relative to work authorized by this building permit application. Signature or Owner Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION 1, , as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and behalf. Print Name Signature of Owner or Authorized Agent Date ISi ned under the pains and penalties o(perjury) NOTES: I. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor (nut registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration program or guaranty fund under M.G.L. c. I42A. Other important information on the HIC Program Lind Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations 110.R6 and 110,R5, respectively. '. When substantial work is planned, provide the information below- Total flours area(Sq. Ft.) (including garage, finished basernent/aures, 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 Lnclosed Open ________ 3. "Total Project Square Footage" may be substituted for "Total Project Cost" 1 S , CITY OF SALEM PUBLIC PROPERTY DEPARTMENT �rAVOa 1 _ 130 WASUPI.ZOM 3MEW*SAtAI '=M 01970 TEL V&7459S" • FA)L$78.7409940 HOMEOWNER LICENSE EXE..MFTION Please Print Date Job Location 31 .L i v `A!5 Home Owner Address Horne Owner Telephone Present Mailing Address Ly 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 lard on which he/she resides or intends to reside. on which there is, or is intended to be, a one or two family dwellin&attached or detached structures accessory to such use and/or farm structures. A person who constructs_'mora_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. HOMEOWNERS SIGNATURE (LONAN� 01W APPROVAL OF BUILDCYG INSPECTOR 4-10-t7 See other side for state code A CITY OF SALEM a 14 M PUBLIC: PROPRERTY DEPARTMENT Construction Debris Disposal Affidavit (required lur ill demolition and renovation work) In accordance ith the sixth edition of the Slate Building Code, 780 CTIR section 1 1 1.5 Dcbris, and the provisions of MGL c 40, S 54; Building Permit 0 is issued with the condition that the debris resulting from this work shall he disposed of in a pruperly licensed waste disposal facility as defined by MGL c 111, S 150A. The debris %villl be transported by: /f (name of hauler) The debris will be disposed of in (name of Iacility) tuddre<d ul lac+li(vt �ry`l�Yd✓c�0 �6 ,� .ignatuie of pcnoit applicant 0 ©0 date