393 JEFFERSON AVE - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards RECEIVED CITY OF
4 ; Massachusetts State Building Code, 780 CMRINSPECTIONAL S�RMESM
evised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling IjI4 MAY 12 IP 0`38
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name) Signatu Date
SECTION 1:SITE INFORMATION
1.1 Property Address: ft: ON n 1.2 Assessors Map&Parcel Numbers
I.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
----------- Proposed Use -.—._.. .-----------
%oning District Proposed Use Lot Area(sy hj Promage(R)
L5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.I.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 iryes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owne ' f Rec
- lz:i�_ Ins 9 --
Name(Print) City,Suite,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other �YSpecify:� C __
Brief Description of Proposed Work 2: —re ot
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
L Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $-.. . /A_c
4. Mechanical (FIVAC) $ List: ski
5. Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
G. Total Project Cost: $ j �S���J 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES ,
5.1 Construction Supervisor License(CSL)
?;,IIyr? E'r.S^74JL1 License Number Expiration Date
Name of CSL Holder
)JF t
List CSI-Type(see below)
C_ ! V4u d+nr
No.and Street - Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted I&2 Family Dwelling
City/town,State,ZIP M Mason
ry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
H
HIC Company Name or HIC Registrant Name IC Registration Number Expiration Date
No.and Street Email address
City/Town,State,ZIP 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 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 APPLIES FOR BUILDING PERMIT
1,as Owner of the subject pfoperty,hereby authorize , IW�`CC. i
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's N;me(Electrof Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
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 halfbaths
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, MASSAQHUSETTS
BUILDING DEPARTMENT
120 WASFUNGTON STREET,3f D FLOOR
�ay TEL. (978) 745-9595
FAx(978) 740-9846
KINIBERLEY DRISCOLL
MAYOR TYHOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COM&HSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date
�f
Job Location
Home Owner Address
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 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
CITY OF S'UE'Nfj ).vL-kSSACHUSETTS
t7L'ILDLNG DEPARM&NT
130 WASI-11IIIGTON SnEET 3'
Ft.00R
TEL (973) 7.15-9595
Rux(978) 7-k)-9M
Kl1[BEl2LcY DlL1SCOI.L
A L�YOR TH0.%t.AssT.PIaRRs
DIRECTOR OF PUBLIC PROPERTY/BCILDLNG CO\OIISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CNfR section I 11.5
Debris, and the provisions of NfGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by i*v1GL c
111, S I50A.
Tlic debris will be transported by:
y
y /k/aca,
(name ut'Itauter)
The debris will he disposed of in
c--
-_—___ (name of facility)
_--_--(adJress of t:cility)
Signature of pci n I applicant -
J.uc --
MORTGAGE INSPECTION
BAY STATE SURVEYING ASSOCIATES INC. JOB#
100 CUMMINGS CENTER, SUITE#316J, BEVERLY,MA., 01915
LOCATION :... NOTES:
�14 f...l�!I�{:f.............. 1)This is a mortgage inspection survey and not an
' QQ instrument survey,therefore this plot plan Is for
SCALE : 1" =34 DATE :....... �.-.9.— .1..... mortgage inspection purposes only. It Is NOT to
a be used to establish boundaries or for the
REFERENCE ' &-'C 4.;(„S_ lT;,,�, -7 construction of any type of improvements.
2)This survey is based on survey marks of others.
••• •''•s Ei� ��' �� � 3)Bushes,shrubs,fences and tree lines do not
.................................................. necessarily Indicate property lines.
/� 4)Whenever an offset Is V+_or less,an instrument
TO:..I �T^ i M �rE/� ,TAS/C survey Is recommended to determine property
......bull.. s)as shown,
lines,and an
The location of the building(s)as shown,either / Y Possible encroachments.
compiled with the local zoning setbacks at the time.of 5)Offsets shown are approximate,and are to be
construction or is exempt from violation enforcement used-onlyforthe.determination of zoning, Not to
action under Mass.G.L Title VII Chapter 40A Section 7 be used to establish property tines. - -
6)In my professional opinion the building(s)are not
located)n the special flood hazard zone,as
defined by H.U.D.MAP# ZS C/O Z &•:$��S"
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IE RV is SEAL IS NOT
.THE PLAN IS A COPY
SR UtD BE ASSUMED TO
+' NTAIN UNAUTHORIZED ALTERATIONS.
THE CERTIFICATION CONTAINED ON
THIS DOCUMENT SHALL NOT APPLY
TO COPIES.