260 JEFFERSON AVE - BUILDING INSPECTION 'i the (Ununomcealth of Massachusetts
t\ Board 111 BLnlding RCgUId(lons acid StandardS I t Ilt
1 NldssachUSCIIS State Building Code. 780 (AIR. 7"' edition \II NII
r t 'SI
Building Permit Application To ('onS11 LIM Repair. Rerun ate Or Demol i,h a K• „•J l nu.,u
(lire- ru- Too-Fmeily [)nedl,in,y
—i
This Section For Official Use Only
- --- ----- — 7
BuilJine Permit Nut ec Date .Applied:
n:pure: -
--- —
fiw ldmf C'onunr.aone I bulx•aur"(Ruddings U:nr
SECTION I: SITE INFI)RNI:\'PION
L� ert \dd •ss: 1.2 Assessors Nlap & Parcel Numbers- --
1 la Is this an acc to street? )es no Map Number _P:uc¢I Vuinhrr
-1
!,3 Zoning Information: LJ Property Dimensions: I
Zoning District Proposed Use Lot Area(sy 11) Froninge (it) —�
1.5 Building Setbacks (fti
From Yard Side Yards Rear Yurd
! R-yuo d Provided Required Provided Required Pro,Wed
1.6 Water Supply: M.G.L c. a0. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood ZoneY Municipal ❑ On ate dis coal s stem ❑
Public ❑ Private❑ Check if yes❑ p l )
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owners of Record:
Nam- (Pnnt) Address tor\Service: n ^ I
h
S enaturc UV Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs)s) ❑ .Alter:uion(s) ❑ Addnion Cl
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Speedy:
Brief Description of Proposed Wor
(Q SECTION J: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
(Labor and Materials)
I. Buildi ire 5 I. Building Permit Fee: $ Indicate how tee a dolennmed.
❑ Standard City/town Application Fee
'_ Electrical 5 ❑ Total Project Cost' (Item 6) x multiplier x _
3. Plumbing Y _'. Other Fees: S
J. Mechanical IHN':\C) $ List:
SSMechanical (Fire S 3
Su ressom) (i(`�l.! Total :111 Fees: S
Check No. Check Amount: Cash \nnaun.
b Fotal Project Cost: SS 0 Paid In Full 0 Outsl:mdin • Balance Due
SECTION 5: CONSTRUCTION SERVICES
5.1 i.icensed Construction Supervisor (CSL)
Luense ,\umher —_—__ I`.tpu'.It:,tn Dale
Nome of( SI.- Ilolder Llst C'SI_ ripe ,cc hcktt l
Wdre,s
l lnl e,tl lcled Ill�I,t�`.IN1U lL I'1 �
— R 1 Re,incted IR_' F,untls Dtt elln!e —�
.SI_n:nurc >I At a>onn Onl%
__. KC Rc,ldcntlal lLtulillp (htrnn
r drnli�l \\l nJnt\ ,tnd SiJII—�c1cpholic \\S Jft-
Sf Rc.tdcnual Sohd I-ticl Ifullnn_ \Itl�h,tnc.' lu.l.il l,iut l�
D Kea dcnlial Denndlu"o
5.2 Registered Horne Improvement Contractor (HICI —
Ii IC C'ontpany Name or IIIC Registrant Numc Rcgutrat!on N'w nher
prpuauou Date
S:gnmwe—_�--- Telephone
SECTION 6: WORKERS' CONIPENSATION INSURANCE AFFIDAVIT (NI.G.L. c. 152. 6 2506))
Workers Compensation Insurance affidavit must be completed and ,uhmitted with this application. Fat l Lire in pntt ldc I
this affidavit will result in the denial of the Issuance of the building permit. - J
Signed Affidavit Attached'? Yes .......... 0 No
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I. -- as Owner of the suhlect property hereby .
authorize to act vu my hchait, III .dt Routers
relate%e to work authorized by this building permit application.
I
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized l gent hereby declare
that the st itements and information on the foregoing application are true and accurate, to the best or my knowledge and
� behalf. — --
Print Name
Signature of Owner or Authorized Agent --- — -- Date
(sign d under the pains and eenalues of perjury)
NOTES:
I. An Owner who obtains a building permit to do his/her own work. or an owner who hires an Linregieteted rontraci,tr
(nut registered in the Home Improvement Contractor (HIC) Program), will not hate access to the aihitiauon i
program or guaranty fund under M.G.L. c. 112A. Other important information on the HIC Progrun and
Construction Supervisor Licensing (CSL)can be timnd In 7SO CNIR Regulations I IO.R6 and I IORS. iespectitely_
' When substantial work is planned, provide the tntilrmanon below
Total floors area (Sq. Ft.I (including garage, Iinished baselrlelu/anlCS, decks or porch)
('tro,.c living area ISq. Fr.) Habit.ible room count --_
Number Lit tlreplaces Number of hedruom,
Number of hathiooms Number of li,dt/hxht
fspe of he:utng system ___._-- Number of deck,/ poncc, -- - --- ------
I I }pe of cooling ,y,tem _ Fn:lo,ed
?. a'otal Project Square Footage" ma\ be substituted for 'Total Project Co,t" __J
CITY OF S.UX-M
PUBLIC PROPERTY
DEPARTMENT
NAYOt ... 130WAWNcr'aMST1Gar0Su®4 =M011M
hL 97}74$-95"• FAY.972•74&n"
HOMEOWNER LICENSE EXEMPTION
Pleaw Print
Date� �--�'-�--
Job Location d
Horne Owner Address
Horne Owns Telephone
Presort 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 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 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 "homeownd'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 ✓4
APPROVAL OF BUILDING INSPECTOR
See other side for state code
• " � > CITY OF SALEM
'r IA; PUBLIC PROPRERTY
^' DEPARTMENT
I1 i 'i'8-'J;-VSIs I'\5. •i'S V:'0.941,
Construction Debris Disposal Affidavit
(required li)r all demolition and renovation work)
In accordance NIth the sixth edition of the Slate Building Code, 7S0 CNIR section 111.5
Dcbris, and the provisions of'v1GL c 40, S 54;
Building Permit 4 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 will be transported by:
(name of hauler)
The debris will be disposed of in
Inamr ut faeility)
laddre5s u(lacililVl -
,ignawre at permit applicant
,late
CITY OR SALKMq MASSACHUSICTTS
GOAR0 CIF APICAL
120 WASHINOTON STRacr, 300 FL.00s
SAL[M, MAS"CMNfsTTS 61070
TtLsPNONst 1670-74i0006
Or AM 07&740-00s0
TO THE BOARD OF APPEAL-
The Undersigned represent that he/she is/am the owners of a certain parcel of land located at:
:; P F F 2 as a r✓ J}km ;Zoning DistricC w ')
and said parcel is affected by Section(s) A - of the Salem ning Ordinance.
Plans describing the work proposed have been submitted to the Inspector of Buildings in accordance with
Section DC A.1 of the Zoning Ordinance.
The Application for Permit was denied by the Inspector of Buildings for the following reason(s):
U I ft, c7 ^? P--4L
The Undersigned hereby petitions the Board of Appeal to vary the terms of the Salem Zoning Ordinance
and allow the project to be constructed as per the plans submitted as the enforcement of said Zoning By-
Laws would involve practical difficulty or unnecessary hardship to the Undersigned and relief may be
granted without substantially derogating from the intent and purpose of the Zoning Ordinance for the
following reason(s):
(PLEASE PRINT)
Owner: P9 I R /as M r= Petitioner:—jai I n AS H
Address: .a6n� J i=F r nS oN A "Ll Address: a 10 /�/
Telephone: / A— `/)L- Telephone: '7 -'-7 C q.)
By: /, - t
(Signature)
Date:
This original application must be filed with the City Clerk. A certified copy of this petition will be returned
to petitioner at the time of filing with the City Clerk, to then be filed with the Secretary of the Board of
Appeal, four(4) weeks prior to the meeting of the Board of Appeal.
A TRUE
ATTEST
CITY CLERK
APPLICATION FOR ZONING RELIEF TO SALEM ZONING BOARD OF APPEAL
Relief Requested:
❑ Appeal from Administrative Decision
Request for Special Permit under Section of the
Zonin rdinance
Request for Variance from provisions of Section of the
Zoning rdinance
❑ Other
( specify)
1 . Owner : i e2 All
Address : A
;) b6 —j �+ T � cznCo ✓ /T ✓r
2 . Location of Property a Zoning
District
Is property located within an Entrance Corridor Overlay District?
�J U
Does property abut a Residential Conservation District?
NU
3 . Lot Dimensions . Frontage Width Depth
Total Area in square feet
4 . The undersigned owns no other real estate contiguous to the
land which is the subject of this petition, except as follows :
5 . Type of use requested:
jZ
6 . A Statement of Hardship must accompany this application and may
be attached to this sheet .
7 . The undersigned hereby petitions the Board of Appeal to vary
the terms of the Salem Zoning Ordinance and allow the Building
Commissioner to approve the building permit applied for, as
enforcement of the Zoning Ordinance would involve unnecessary
hardship to the petitioner and relief may be granted without
substantially derogating from the intent and purpose of the
Ordinance. ij t
Petitioner : /I'-
Address : ILAe t,, !?�, C >
(signed)
FEE PAID $
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