319 JEFFERSON AVE - BUILDING INSPECTION (2) r. t
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I'he Cunununsceahh of Massachuscl(s
Board ol'Iluilding Regulations and Standards CI IN OF
Massachusetts State Building Code. 7'd0 0011 �.\LI:.\I
Building Permit Application To C'unsirtict. Repair. Renurue 0 eniolis a
(fie-ur rlru-P'unity Dlrelliup
This Section Fur 0lrcial Use 0ermit Number: Date Applied:011icial 114mt Mane) Signalure )a e
SECTION 1:SITE INFORIIIA AJ ress: 1.2 AssessursMap& Parcel Numbers
1 Sy+. �4✓�an accepted slreel? ,es no Map Number Purccl Numhur
1.3 Zoning Information: 1.4 Property Dimensions:
zoning District Proposed Use Lot Ann(sq M Frontage(11)
1.3 Building Setbacks(R)
Front Yard Side Yards Rest Yard
Required Provided Required Provided Required Provided
1.6 Water Supply.,(M.G.I.c.40.154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Mobile O Pdvute O Zane: _ Outside Flood'Luna? Municipal 0 On site disposal s)stem O
Chock if csO
SECTION2: PROPERTY OWNERSHIP'
2.1• wiser
of Rec rds / "A
,,A O 1 n 7 C
Uyr �' GJ /�/ 7
N;nn trr n city.slate.zlP
319 �.ti.. �(�
No.and Street rclephune Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteratlonis) O Addition (3
Denwlitian 0 Accessory Bldg.O Number of units_ Other 0 Specify:
Brief Descripption of Proposed Work`-
Ce• Q In ..- n W errna
L�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Items Estimated Costs: Oflleial Use Onl
(Labora d .Materials) y
I. Building S I. Building Permit Fee: S Indicate how tee is determined:
'. l:'learical S 0 Standard City.Tussn Application Fee
0 Total Project Cost't Item 6)v multiplier
1 I'lumhing S 2 -- -
. Other Fees: S.
a. Mcci,anieal I II\ W) S List:._
\IvOmnical --•—
i .u1uc.'siunI S renal \it Fees: S .__ .-_ .. ._. . ._ . .
Chc" No. ( heck Anio a t: Cdoh \mount:
n Total Project C', S ��� O P.,iJ in Full ❑Outstanding Ilal.mce Me:
s ,
SECTIONS: ('0NSI'RI1("r10NtiF.RVI('F.S
5.1 ('unstructionSupervisuri,icense(CSI.1
I icense Nunther _ ... I'\piraiou Mate
N;mteol'l'.CL IIoldef Ilitl'.Sl. l\pelscehclu„1.__,_ _
No ,slid S(recl
Is lliveiifidedl Moldings ti 1o14,UII11al. IL1
R I(e,triovJ NO p.mlil Docllin
%I Slasun
HC R,soin )mein
A"i Window.Ind Sidin
SF solid fuel homing Appliques
I Iilill1a110n
l'de hone Finail;oldreis D Demolition
5.2 Registered Ilume Improvement Contractor(HIC)
IIIC' I(egWrallon Numlter Iiµrirll(on 13119
I IIC Cbnlpgl) Nanlc or IIIC I(egiitrunt Nin1c
Nu. aW SWeI - fanail address
City/Town. State ZIP Toe hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 157. y 35C(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 .......... G No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property,hereby authorize
to act on my behalf,in all natters relative to work authorized by this building permit application.
Print U,.ncr's Na is(Electronic Signature) Dora
SECTION 7b:OWNERI 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 a lication is true and accurate to the best of my knowledge and understanding.
t /-7 fro/Z
1'ria117„ncr'i or:\ulhorireJ,\gem'i N;unu II(lectnmie Signature)
uW
,NOTES:
1. An Owner who obtains a building permit to do his.her own work,ar an owner who hires an unregistered contractor
(nut registered in the Hume Inlproventeat Cuntracturi HIC) Program).will lira have access to the arbitration
program or guaranq fund under\I.G.L.c. 1 J?A.Other important information on the HIC Program an be titund at
I Information on the Construction Supervisor License can be found at,,,,'� ul,t.• :'� 'tl„
\\'hen substantial ,wrk is planned,provide the int'urnntion below:
rota) (lour area 11+ Il.l _ ____.._I including garage. finished basement alties.decks ur porch 1
Gruii lis ing area 114. Il.I _..._ _ ftubilable room count
t \unsher of lireplacci _ _.... _... . Number ulbedraunts .. ..
quuherol'hadlnwnls -- Numberufhallhall's
I,N Ilk:kit heating i)ocat \'unlhet oiJecki• porchci
11 pu�'I aa,ling :)+tcm L'nclu.ed . .l)pars '
1. "I, 1,11 1'fU�eel ti,IlGlrti Foolace nla% he uh,nititQd for"1',1(.J Project Colt-
f"r
CITY OF S.U.E.M
PUBLIC PROPERTY
DEPAR' , LENT
w ouaar o�ara�a
Wry I b v..wtoGnm suers•sxa,K V&.oAowsar7s otr.o
7YL 1'8.745.9s"•VAX 978.744964
HOMEOWNER LICENSE EXE.MMOH
Pleass Islet
pate �F I ol�
Job Loeadm
Home Owoar Address .ef
Hom.Owner Telepbone —
Preamt Mailing Addrasas s0-yy.-e-
The current exemption of"Homeowners"was extended to inchuds owner-occupied
dwellings of two Units or legs and to allow such homeowners to engage an individual for
him who.does not possess a ficrosm provided that the owner acts as superWaor.
DEFINMON OP HOMEOWNER
Perton(a)who owns a parcel of land on which Itdshe resides or intends to reside6 on
which there is6 or is intended to bs6 a one or two family dwroging,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 shag not be considered a homeowner. Such
'-homeowner'shall submit to the Building Official,on a form acceptable to that 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 impaction procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING NSPECTOR
See other side for state code
Y
CITY vE S.1t.&Nf, AIISSACHUSETTS
OL'tLCLVG Cer.1ATJtE`T
I A W-UHNGTON SrXIV, J'e FtCC jt
raL k979) 141.959S
KIJWERF YORIWOLL FAX(973) 140-9W
MAYOA MO..%&USr.PMUA
Otltscrox OP Pt:SLlC PROPlA7Y/3L QALNG C0►C%1tS1tON E1{
Can9tructioa Debris 015pos21 At'tldavit
(required for aU demolition and renovation work)
(n ac the r with
ri Debs, andd the the sixth editlon of the State Building Code, 180 CM section 111.J
provisions of MGL o 40, S 34;
Building Permit At i
1 11 If, $ I JOA. s issued with the condition that the debris resulting from
I work shall be disposed of in a properly liceaaed waste disposal racility as defined by NIGL c
The d bfiisI will be transportedby:
(n,+me u hhauler)
The debris will be disposed of in :
(nameo
(J'Ar0fl or rivilay)
"javure uf;,ermi f ippi.:Inf