73-75 LINDEN ST - BUILDING INSPECTION (2) The ( ommoime:dth of Massachusetts
t y 130ard of Building Regulations and Stwidaids ult
Massaehusetis Sate Building ('udc, 7ti(1(AIR. 7°i eJitiun \11 Vle II' \I I 11-
;...,r
13ui1Jing Permit Application To Construct. Repair. Renoiale Or I)rnnplish a NruprJ l,piu„u i
�\ ( Ie- rir ruo-l�arnilr Dirrllin,C
tys" 'Phis Section For Otficial Use Only
Building Permit Nun er: Date Applied: .�. _c>o
Si_natui-e it
:
�O
Bull mg Conunisao nspecmr of Buddiugs Uulc
_ SECTION 1: SITE 1.\'FURJLA'1'ION ---- —
1.1 Property address:77s' L/noe t 1.2 Assessors;Assessors; .Ylap & Parcel Numbers ------ --
—Z3- ff
I.la Is This an accepted slfer17 ses nu Map Number I':u.ct
1.3 Zcning Information: 1.4 Property Dimensions:
"'...:.:•: y tl l fluina do I li 1
r1 5 Building Setbacks lfti — ----�- --
—T.__..—_._—_ 7
Front Yard Side Yards
F--- Rear Yard
ReyuireJ Provnicd Required Provided Re cared
y Rr,i idrd
I !.6 Water Supply: I:�1.QL r. 10, §S1/ 1.7 Flood Zone Information: I.8 Sewage Disposal System:
Public'❑ Private❑ Zone: ._ Outside Flood Zone:'
_ Check it yes❑ ylunicipal ❑ On site disposal sy>Ic in ❑
SECTION 3: PROPERTY OWNERSHIP'
Z S Owncri of R ord:
-. Lr,�/«IIeK S —
N.wx I P lilt)
Address for Sel'bll C:
Sipvaure ___ Telephone --_-
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction (7 Existing Building Ow er-Occupied Repairs(s) CYO .Alteraurn(s) ❑ AdJini:n ❑
r>emolition ❑ Accessory Bldg. ❑ Number of Units
�_ Other ❑ 'n.. ly
Bncf Description �,,t Proposed Work':
i c --
SECTION a: ESTIMATED CONSTRUCTION COSTS
i ;rem Estimated Costs:
f Libor and Materials) Official (Tse Only
IjlFle�tiical
Building g 1. building Permit Fee: $ Indicate haw tee Ls delcnlilued
2. S ❑ Standard Cry/fown :\ppliration Fee
❑Total Project Cost' (hem G) x multiplier x g _. Other Fees: S
al IH\':\C) 5 Lisr.al (Fire) 4 Total All Fees: $ - ----
Check No. ('hark :\mount: ('ash Amount
b Fatal Project Cost 5 a,�UO I ❑ Paid in Full -- - -
❑ Outstanding Bali ue Due:_
�i
i
'
SECTION 5: CONSTRUCTION SERVICF,S
5.1 Licensed Construction Supervisor (C'SL)
-- N ,// Li.cn>c N'unlhcr I',pmolon U.n.• ..
C'51.- IIoider I`7 I.ul CSI_ 1\pe occ helou 1 -----
Type Descn ,eon
\Jdre Ss ( l'ioe,olcteJ ,u to }>.1 N)U( u Pl
R Restnaed L@_' F.mnll O-elliue --�
\1 \l:uonr\ Once
ShInaulle
R
RC esldrnual Ruulinc(main`_
I cIeplNmr _ \\s Re ad:nn al \\LWu.. ,111J
SF Rc,I&iloal Suhd I-url ISwmne \l+l,l i,m:: Iml.il l,nnai
p Re�lJcunul Uanolwun
5,2 Registered Ilome Improvement Contractor(HIC)
Regutiauon Numher
IjIC Company Name or HIC Registrant Name
-\Jdress F.vpiratirm Ma%:
Telephone
lleviature
Alil
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (LI.G.L. c, 152. q '-�C',
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to prll\lde
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
as Owner of the subject property hereby
to act on my behalf. in all matters
authorize
i
re!ati ve to w•.�l's authorized by this building permit application.
Data ----------- --�1
$i nalule on Owner
SECTION 7b: OWNERt OR AUTHORIZED AGENT DECLARATION _1
r :nc) , as Owner or Authorized Agent hereby JCChlre
[.
nd accurate, ul the best of my knowledge and
that the statements and infer ation on the foregoing application are true a
b , f.
e d
Pont tne
Date
Sia,lature of Ovmer, ra
or Authl zed Agent
(Signed under the' ❑ins and enalties of e(❑ 1 NOTES: -{I
I. An Owner who obtains a building permit to do his/her own work.or an owner who hires an unregi,tetcd ctmtra tol
(not registered in the Hume Improvement Contractor(HIC) Program). Will nut have access to the athitration
program or guaranty fund under M.G.L. c. 113A. Other important intolmanon on the MC Progr:un and
Construction Supervisor Licensing (CSL)can he timnd in 780 CNIR Regulations I l0.R6 and 1 I0.10, re,pecroclyn be ow
_ When ,ubstantial work is planned. provide the intixma^`luding garage. tint\hed bapC111Cn U:1n1C 1, decks of pulihl
Total floors area(Sq. Ft.) Hahitable room count --
I (;ros.s living area 1 Sy. Ft.) Number of hedroom, ----
Numberof tireplaces Number of h.dt/h.uhs ------
Number of hathioorns Number otdeek,/ porchc, -
fvpe of heating sv,tem --
T\pe Ut owling S1'Stem —y
SUbehlUtl'd fur project ( u,f
Z. Tolal Project Square Footage" may he final
CITY OF $AI.EM
PUBLIC PROPERTY
DEPARTMENT
- - 130wA"NGTMSMW 0 SALMNASSACIn.•WM01970
To-978-745-9S"0 FAx.976-74&9&M
HOMEOWNER LICENSE EEC MMYON
Plea"Print
Date
Job Location 73 " 75� c�i�ro eert J'�•
Home Owner Address
Home Owner Telephone 27k 7 -
Present Mailing Address — n
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
hire who.does not possess a license,provided that the owner acts as supervisor. s
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 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and iepifelnents.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SALEM
I J, PUBLIC PROPRERTY
DEPART'vIENT
I'i
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance \pith the sixth edition of the State Building Code, 780 Ch1R section 111.5
Debris, and the provisions of NIGL c 40, S 54;
Building Perrnit h is issued with the condition that the debris resulting from
this work shall he disposed of in it properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(>
(name of haul?r)
I he debris will be disposed of innn: // f
l - ,, l/1 S
(name of facility)
(address of facilily)
--- .. .tiienature of po \it applicant
� XA
._ date — ---