42 IRVING ST - BUILDING INSPECTION 5s t
t The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 20II
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official;Use Only
Building Permit Number. Date ]16d;
1 J hiding Ofcial(Print Naive) Signature Date
SECTION 1:SITE INFORMATION
� 1.1 Pr er[y Address: r., 1.2 Assessors Map&Parcel Numbers
J� 1.1 a Is this an accepted street?yes no Map Number Parcel Number D _,
1.3 Zoning Information: 1.4 Property Dimensions:
t.
Zoning District Proposed Use Lot Area(sq 11) Frontage(ft) r14
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: PROPERTYOWNERSIIIP'
2.1 wnerr of Record:
Q 1 rvt. r•G Salell� Ah
ame(Print) City,State,ZIP ® 1 cl7 O
Sr v\v`a ���e�'T y'n-31-7-499 3
No.and Sneet� Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work-2: A (-F aan y�e_ 1'nn F
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OfScial 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 Cost'(Item 6)x multiplier It
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
Mechanical (Fire Suression
$ Total All Fees:$
/r�T Check No. Check Amount: Cash Amount:
6.T tal Project Cost: $ V V ❑Paid in Full ❑Outstandutg Balance Due: ..
Mat�.cp (P 1 t-3
SECTION 5: CONSTRUCTION SERVICES
t
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type .1)eseripfion..:
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted l&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
1 Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
•� ` HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and;Street Email address
Ci /Town State,ZIP Tel hone
SECTION 6:WORKERS COMPENSATION INSURANCE AFFMAVIT(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 APPL,IES.FOR BUMPING 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.
I
Print Owner's Name(Electronic Signature) Date
SECTION'71r: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 ac ate to the st of my kno dge and understanding.
r It,r•e ate 2016
Print Owner's o Authorized Agent's a ctro ature) rt D
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
wtivw.mass.govtoca Information on the Construction Supervisor License can be found at www.ntass.>ovt /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
BUILDING DEPARTMENT
120 WASHINGTON STREET,3RD FLOOR
w_ ns TEL. (978)745-9595
FAX(978) 740-9846
KIMBERLEY DRISCOLL
MAYOR THOMAS STTIERRE
DIRE CTOR OF PUBLIC PROPE RTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
6 Date 16` 1 Job Location "I �- f V t t^� �� >/�odeyyx /r/�
`A , d 1 9 7 o
Home Owner Address SA rn
Present Mailing Address SC 0A
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
APPROVAL OF BUILDING INSPECTOR
CTYOFSALEA A ASSAMUSEM
' BEnDmDEeAimmw
120WA9MVXKSnM,3" Octt
TAL(i78)745-9395.
FAX(97i)74D-""
%D�ERLEYDRiSfx7l.L
MAYOR 91MAsSTAMM
Dmcrcit cjPPuaucFxcrwY/Btz=4Gocmmcmm
Construction Debris Disposa/Afdavit
(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 coo, S 54; Building Permit 8 is issued with the
condition that the debris resulting from this work shag be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by.
(5Iais Cap g z— zo 9 2>
(name of hauler)
The debris will be disposed of in:
.SakrA `Trans Fe- r Sfiafi�r�n
(name of facility)
(address of facility)
§igna'tVtrg of applicant
G <6 16
Date