73-75 LINDEN ST - BUILDING INSPECTION (3) The Commonwealth of Massachusetts
^� Board of Building Regulations and Standards CITY OF
SA EM
Massachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct, Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For OfficiaLltlsls,Only
Building Permit Number: I.Date plied: - •*
Y1 Budding Official(Print Name) - Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Alldrpsf,: 1.2 Assessors Map&Parcel Nu b rs
93-7s' to za a gem mfF
1.1 a Is this an accepted street?yes ✓ no Map Number Parc Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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 C2r Private❑ Zone: _ Outside Flood Zone? Municipal 01-On site disposal system ❑
Check if yeses
SECTION 2: PROPERTY OWNERSHIP' _
2.1 O 'ner'pf
Ed,ord:J /
E/ram rd 1 arl�nQ �V lerm Mig OL il7U
Name(Print) // City,State,ZIP
77-7.S�G/1'./et Imo• 9W-N".?W P,1 /u�GoancaJ ne f'
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) _
New Construction❑ Existing Building arl Owner-Occupied 521' Repairs(s) 5( Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units I Other ❑ Specify:
Brief-anDescrip ion ofP opused Workc: mu E iJ is ear o- o
e S S�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ /�pp . 1. Building Permit Fee: $ Indicate how fee is determined:-
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item6)x multiplier x
3.Plumbing $ I2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees:$
Check No. Check Amount Cash Amount:
6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5c''CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
N//Q License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Tele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
/y! 4 HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town, State,ZIP Telephone
r 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 COMPLE ED WHEN - -
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUIL NG PERMIT
I,as Owner of the subject property,hereby authorize
to act ���n all relative to work authorized by this building permit a�plication. /
}� 7 070 //
Print Gwner's Name -lectron ignature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
i
By entering my name below,I 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 Ili
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
wwce•.mass.eov/oca Information on the Construction Supervisor License can be found at www.gtass.ggov'dos
27 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 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 E.Nf, L&LASSACHUSETTS
BULDLNG DEPARTNONT
110 WASHLHGTON STRM, 3'FLOOR
I1n. (978) 745-959S
F.Vt(978) 740-984
KIJ®ERLBY DROLL
MAYOR THows ST.Ptam
DIRECTOR OF PLBLic PROPEATY/BCILDLYG CMNISSIONER
Construction Debris Disposal Afriidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section l 11.5
Debris, and the provisio
ns ns of MGL c 40, 3 54;
Building Permit Al 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 MGL c
111, S 150A.
The debris will be traansportcd by:
�
",, , '/' h 1' -, f
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permi applicant V
7 ,
date
LM1n ud.Lw
CITY OF S.ULE.NI
PUBLIC PROPERTY
DEPARTMENT
U fatYat ti.rvr i
v'""Oe i b v.auw.�4r..ar•s�u,�Vwsuowsarn Ots-o
ns.• e-7is•9sts•FAX 975-7409e1e
HOMEOWNER LICLNSE EXEMMON
Pfeaw Feist /
Job t.ceadom 7—s- < �l« t/l
Home Owner Address i/'/a A
Home Owner Telephone
Present Mailing Address
Tie current exempdoo of"Homeowners"was extended to include ownw-occupied
dwellings of taro Units or left and to allows such homeowners to engage an individual for
hire who.does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of Led on which he/she resides or intends to resider on
which time 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 wort 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'certifles 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 requir l rs
HOMEOWNERS SIGNATURE l7
.APPROVAL OF BUILDING INSPECrall
See other side for state code