236 JEFFERSON AVE - BUILDING INSPECTION pp - fhc ('rnitnntnaaraI(h ul III IJSsathuSCux - ---- - ---
9 Board of Budding Rcgulauuns .tnd Standard, t
\I:r"a. IIusells Slue Building Code. 780 ( 'SIR. 7i' cdintm
1 Building Per :Application To Con,f 'ucl. Repaii. Renot.rte or WI TIoli.h ,t
- I)tie- nrTn'r,-1,uniA' (hrllirrt,
fhts .Sernun Fur� octal ('se Unly
Building Pertml Nunn er Dat .1 pha•d:
j HuIIJIIIF('unum..lun:I, Iml><.Ior of Htu IJIltg, D.ue .
I _RF'('"''ION l: S1TF: 1.\FORON
1.1 Pruperh_ \ddn+s: I 1 Assessors \lap & Parlll Numbers
FFEV.SoN
— —
1 1 t 6 this m 1 'Ca tit J \..tnh:.
1.4 Properly Dimerr •ets: ------ .
Zoning Duincl Proptrx•d Uu Lot Area(,y Ill ! t'uuluge It t�
l_5 Building Setbacks (ft)
F----Fri�mt Yard Stde Yard. _—_ Roar Yard
Keyuu.JP l Pro':Ided Ra' mieJ -- --r
a 14 - _ Pnntded Kcyuu eJ I Pt,„tJc�
I
rI.T.6 "Water Supply: t.N G L c. J0. §5 4) 1.7 Flood 7_one Informatiue1.8 Sewage Disprrlal System:hlc ❑ Private❑ Zone. — Outside FhxrJ Zone
Check if yes❑ I %huunpal ❑ On ,tic Jt.pusal a,I:Iu ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner]of Record:
S
Hum inT£FEl1 S \JE-
e nnU Address for Servtcc
yl ' ol-) /} I
--'— 41-t`i�� _ y13-- 234- Ssy
I r naW c Telephu iei
I SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply) j
r— —I I Ne•.v C„rotnrruun ❑ F.s fisting Buildin---Z—g ❑ 1 Owner-Occupi ed ❑ Repaua(,—) ❑� \Iteruunnl+) ❑ ,\J;ltu„n ❑
Cemulitiun ❑ _ AI cce:,st:,�v g;dg. ❑ Number ut'Umts_ I Other ❑ Spert
f.)nef Des;;riptiun u(Fnq;,sed \V,rrk-: 7(ICW r'oo±d)�4--T� pH2. 11�yetr_
SECTION J: ESTLVIATED CONSTRUCTION COSTS
Estimated Costs: - — - —i
! It"n Official Use Only I
tl.abur;tnd M1taten;.tlsl y
1 ButlJute y 1. BwlJtng Perms Fee: 5 IIId IC ale tum I" i, ;1C;Cl Irmcd
Eleanral 5 ❑ SLmdard i ity/Town Apphc,utr,n Per
❑ Total Pnpecl Crtstt I Item 6) t multiplier
i. Plumhing 5 '. Other Fees: 'S _ . .
F- --
J \ircha mcal IH\':\Cl 15 Lnr -
i Slcahamc.d rFn'e
/i �uppresunn S � f,n.t1 :111 Fees: 5 __—_ _ ------- --- -
(/ I )"heck .V,r l'heak Ain.,unt ('.nh \m,wnt
n ['alai Project Cult j 3 000 , OCR --.---
! ) ❑ Pald m Full Outa.tnJnt,' B.tl.une I rue
i) f'04th 1Ma�uS
G.Ito t-VeP2 Fe.Ilew skliP CJAv.rcin I
►l0 2,eecLa Sh.
1) C4,,,,!.Ct 92 ) Met} Oa040
SECTION 5: ('ONSTRi_.CTION SER"i ICES
F
;.I Licensed Construct lull S-11pe"isor I CSIJ
to
S1. I kiv 'cc hCh",I
Do"I-IL011
lli,Io F,
"'21 1 milk 1)",:11 11" ---------
R
Ma"Illis )Ilk
sl�ll.lttllo
It""Icilti-d sol"I 1 .,C!
1)'Illok!".11
5.2 Registered [ionic Irnpro%enient Contructor till(')
I I W Colill,...... Nallic or IIIC R"_vuallt Name
relepliolle
S'platule
SECTION 6
WORKERS' COMPENSATION I NSU RA NCE A FFI D A N IT ii NI.G,L, c. 152. S 254,16)
ide
Workers Compensation Insurance affidavit must bec,unpleted and submitted with this ILPI't"all"ll F.LLIOICt" pro
this affidavit will result in the denial of the Issuance oI the building permit.
Signed Affidavit Attached? Yes 13
0 BE COMPLETED WHEN
SEC I, I All: I'llqEltAUTHORIZATION'PLIES FOR BUILDING PERMIT
OWNER'S AGENT OR CONTRACTOR APPLIES a,Owner of the lllbl'--cl propel hereby
;alcuee to •.cork authorized by this building permit aPplWIll"In
[Date
sjelature of owner SECTION 7b: OWNER OR AUTHOR[ZED AGENT DECLA RATION
as Owner orAuthowcd .\,,cnt heteh) det.laic
1.
_�V*is) V\A V�y ue and accurate. to the best�)t my knowied-
that the statements and informaticirion the foregoing application arc it
behalf.
i-it l,�_ IV,,va,%SV S
rill jam J U
Due
Swia ire ol Owner orAuthotized Agent
tst , d under ilhe NOTES:
Owner whoohlims a building permit to dt) his/herown koik. ,r an owner whithires III L 'rlIeCPISICICJ C"1111:1"'Il
I. An(ji,it registered in the Home Improvement Contractor (111C) Program). will not ha,,eacce- to the ,uhriml,lo
p,(,L,rarn or guaranty fund und under M G 1, c 1.4'A Other Important int,qrnation on the MC Pr,,p.unArid
Reeulations 1 11) RO •ind 1 10 R5,
0,risittown Sup er,,is,u Licensing iCsl.) can he tmind in 71M('MR - I!
�I)%ide the intoi mation decks or 1),�l
I when labsian"Al work is planned. pi hclk,w
imcludine ujrj,-e. tini,hed
Total tillirs area Sq. Ft.I
l,'
Hahrable Il'orn count
61"'s living ilea (Sq. Fr Nionher l-t hCdro,,in,
miriberct NLImheror 11,11Ph,ith,
Nurtibel ,I jc,k,I j),,i,lble,
I ,,pe M
Prlject SIILI,IrC he uh,muted t,,r
14 i
CITY OF SALE.N1
PUBLIC PROPERTY
DEPARTMENT
KIlOy� cv tvwvv
130 WASUNCMN S-MM♦S 1XK UA=AOR'SERS 01970
TEL 978-74S-9S9S* FAx 97674-964
HOMEOWNER LICENSE EXEMPTION
Please Print
Date R- l(o- moo y
Job Location A 3 Co
Home Owner Address date T t T= CL Son1 f!J
Homeowner Telephone �—
Present Mailing Address
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.
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 understands the City of Salem
Building Department minimum inspection prpcedures and r uirements and that he/she
will comply with said procedures and r ents.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING CUSP CTOR
2�-
See other side for state code
< s CITY OF SALEM
PUBLIC PROPRERTY
D EPAR'I'MENT
.. .\l : .• , I:� Ur• IIV.., ':1:SIIr � �.\II \1. \t �.,;1 -. •. I • . I' :
III 1',l'.'14.a-yi • I \: 'i.'Y.•!_ 'KL�
Constrtiction Debris Disposal Affidavit
(reLluired li)r all demolition and reno"Ition work)
In accordance \%ith the sixth edition of the State Building Code, 7S0 CNIR section I 11 5
Debris, and the provisions of'v1GL e 40, S 54;
Building Permit it is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal lacility as defined by MGL c
l l 1. S 150A.
The debris will be transported by:
manic of hauler)
I he debris will be disposed of in
(namr ut facility)
laddres< ul 1]ulitvl
'1platuic of pcnnn applicant
,late