9 LINDEN ST - BUILDING INSPECTION o� 7�1
r The Commonwealth of Massachusetts
ky Board of Building Regulations and Standards =a *kddwbdw&
of
Massachusetts State Building Code, 780 CMR, 7'"editionDept
Building Permit Application To Construct, Repair, Renovate Or D
Ot Tiro-Family Dwelling
This lection For Official Use Only
Building Permit u er: Date Applied: �7
Signature: ' 0
Buildin Comm oner/ iorof Buildings Date
SECTION 1: SITE INFORMATION
1. operty Addr, . 1.2 Assessors Map& Parcel Numbers
I.[a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(R)
1.5 Building Setbacks(ft)
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: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check ifyes0
SECTION 2: PROPERTY WNERSHIPt
SDemofition
t of Record: To r..( m�t Iq(—
p e l [� ra Y // L 1 l t c�Piyt J[ _
Address fo ervice:
ge� 7� -930 - Y7LEJ
TelephoneSECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
ction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
tion of Proposed Work': o t
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Onl
Labor and Materials y
I. Building S 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing 8 2. Other Fees: 5
4. Mechanical (HVAC) S List:
5. Mechanical (Fire $
Su ression Total All Fees: b
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S ' /�� 13 Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Con, struction Supervisor(CSL) 1
�•- Exp
\\ License Number iration Date
Name of CSL- Helder List CSL Type(see below)
T escri Lion
Address U Unrestricted(up to 35,000 Cu. Ft.)
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC Residential Roofing Covering
Telephone Residential Window and Siding
SF -Residential Solid Fuel Burning Appliance Installation
D Residential-Demolition
5.2 Registered Home Improveme Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address /�� Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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 Affidav Attached? Yes .......... D No ........... ❑
SECTION 7a:O NER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGEN R CONTRACTOR APPLIES FOR BUILDING PERMIT
1 as Owner of the subject property hereby
authorize to act on my behalf, in all matters
relative to orized by thi uilding permit application.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
S(y1-2 eXII 2 V-cf)td� , as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are We and accurate,to the best of my knowledge and
behalf.
tM
Print Name Cp 7 O
rized AgEtSignaturedOw ho
signed ufr thnoAutd enalties ate
ofperjury)
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and 110.115, respectively.
2. When substantial work is planned,provide the information below:
Total floors 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 half/baths
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 SM.EIM
PUBLIC PROPERTY
DEPARTmENT
IV,yCV flLHYY
NAWM 130 WASMNGT w SIUM 9 SAI M NA9MCK SWM 01970
TM-976•745-95"• FAX 97$.74696"
HOMEOWNER LICENSE EXEMPTION
Plow Print
Date G a
Job Location CV/1-1
Home Owner Address e oR 76
Horne Owns 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,don 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 structure. 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 procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SALEM
PUBLIC PROPRERTY
DEPART?�IENT
,:
I'C U.r;ni >C:+tri s ti.V nt, )1A"t( ir :; i ,
V,S-74i-),15 I .\X: 778.74�- 9846
Construction Debris Disposal Affidavit
(re(luired lur all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # - _ is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I11. S 150A.
The debris will be hansported by:
S/Y✓t'2Q.yL Yc)�Wv( l ! �'�"'t �iL1 1�E 1 p
(name of hauler) I
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit applicant
C
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