412 JEFFERSON AVE - BUILDING INSPECTION (3) Jl I The Commonwealth of Massachusetts
Board of Building Regulations and Standards
CITY
Massachusetts State Building Code, 780 CMR, 7"edition OF SALEM
'w Revised Jumiory
Building Permit Application To Construct, Repair, Renovate Or Demolish a l. :uur
One-or rwu-Family Dwelling
This Sec"ion For Official Use Only
Building Permit Number Date Applied:
Signature: q�t�
Huildinj C miss for of Buildings ffale
SECTION I: SITE INFORMATION
1 ropert!Add ess: 1.2 Assessors Map dt Parcel Numben
I Jz J�A 10
1.12 Is this an 2CCCroted street?yes no Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
13 Building Setbacks(R)
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: 1.2 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public O Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 nert of Record:
01n� eN b- g 12
No (Prin Address Service:
/ '37R1 156i
sign am Telephbric
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work-, c r
9 ' x
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building is 11. Building Permit Fee:s Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical is ❑Total Project Cost(Ilem 6)x multiplier x
4. PlumbMechanical
S 2. Other Fees: S= ZZ4
4. Mechanical (IIVAC) $ List: +{—'��
S. Mechanical (Fire S
Suppression) Total All Fees:s
cn Check No. Check Amount: Cash Amount:
6. Total Project Cost: S J 060 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Iyate
Name ot'CSI.- I lower List CSL Type(see below)
f Description
Address U 1lnrestticteJ u to JS,000
R Restricted 132 Famil Dwelling
Signature M M (MI
RC Residential Routin Coverin
fdephone WS I Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D ]Rensidemial Demolition
5.2 Registered Home Improvement Contractor(HIC)
I11c Co me my Na or IIIC Registrant Name Registration Number
Address Expiration Date
Signature Telephune
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,e. 152.f 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 ..........O No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 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. -
Siantaure of Owner Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
1, �n P as Owner or Authorized Agent hereby declare
that the�tements and infarmatto n the foregoing application are true and accurate,to the best of my knowledge and
behalf.
,—ae yl M ,
Pri e U
C� �U 23 2 h1U
Sign ) at Owner or Aomori Agent Date
Si under the pains and peniltics of 'u
NOTES:
I. 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 Sg have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.RS,respectively.
2 When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basemenVattics,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 healing system Number of decks/porches
Type of cooling system Enclosed Open
J. "Total Project Square Footage" maybe substituted for"Tolal Project Cost"
CITY OF S.U.E.NI
PUBLIC PROPERTY
DEPARTMENT
Kl f0laLi11 n�w.vv.
Vwrw 130 WAMMGMN MM•sALM MA.aAo&MM 019-0
r9j-r../-7JL7S9S• FAX 975-740.9W
HOMEOWNER LICENSE EXEIMMON
P1tass trtnt / .
Date Z3 Zo 16 v /
Job Location )Z
Horne Owner Adtims S✓t vv�c_
Home Owner Telephone � i
Present Mailing Address 4•I z
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.
DEFINMON OF HOMEOWNER
Persons) 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 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
OflticiaL that he/she be responsible for all such work performed under the Building
Permit
The undenigned "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 procedures and requirements and that he/she
will comply with said procedures and requirements. /
HOMEOWNERS SIGNATL JC
APPROVAL OF BUILDING NSPECTOR
Sce other side for state code
CITY OF SALEM
-� *\ PUBLIC PROPRERTY
DEPARTMENT
TiI II\i. N 1110:I T ♦ $.\I I \I,
I n: 'C8.,'45.7i'15 • 1:\\:7'S 73J9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In :Iccurdance with the sixth edition of the State Building Code, 780 Ch1R sect ion.1 1 L5
Debris, and the provisions of NiGL c 40, S 54;
Building Permit It is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I I t. S 150A.
The debt-iswill be transported by:
-... .. (name of hauler)
'I lie debris will be disposed of in
(name ul laclhty)
T
' uldres.c uf'lacility)
.ignaturo of prrm�pplicant
7 Z3 Zo b
(late