73-75 LINDEN ST - BUILDING INSPECTION The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
1 1h
Massachusetts State Building Code, 780 CMR, 7 edition
Mas Buildingp
t.
Dept
Construct, Repair. Renovate Or Demolish a
Building Permit Application To Cons p �
\ One- or Tvo-Faintly Dmelfing,
V` This Section For Offici se Only
Building Permit Number: D e Apph
Signature: °��'►"� � /d 0
Building Commissioner/Inspector of Buildi s D
SECTION 1:SITE IN TION
/1 1 Prop rty A dress: L t 5.� 1.2 Assessors Map& Parcel Numbers
r�
1.la 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 it) Frontage(R)
1.5 Building Setbacks(it)
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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if Xes0
SECTION 2: PROPERTY OWNERSHIP'
2.1 OwneIJgof g Id �v
V A dress for ervice:
Name(Print)
ignature - L Tel phone
ECTIO : 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 ❑ Specify:
Brief Description of Proposed Workr: rl7 '"� ✓ g • ��,
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
1. Building E I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S Total All Fees: S
Suppression)
Check No. Check Amount: Cash Amount:
6. Total Project Cost: Sale/ow, 13 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL- Hplder List CSL Type(sec below)
a
Address T Description
U Unrestricted u to 35,000 Cu. Ft.)
Signature R Restricted 1&2 Famil Dwelling
M Ivtason Onl
RC Residential Rooftn Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D FResidenlialDemolition5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Number
Address
Date
Signature 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 ro subject� property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTIM 7b• OWNERt OR AUTHORIZED AGENT DECLARATION
Lbehalf
' ,'as Owner or Authorized Agent hereby declare
ents and info rrott'the regoing application are true and accurate,to the best of my knowledge and
nerorAut or ente pains and enal es of verju
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 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 I 10.115, 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 SALEM
r 4 PUBLIC PROPRERTY
DEPARTMENT
q:
III ' '/'8 'i:.F"S 4 1 \S' 978 '4-".i4,,
Construction Debris Disposal Al•tidavit
(rcyuiICd Ibr all demolition and renovation work)
I
In accordance %pith the sixth edition of the State Building Code, 7S0 CNIR section 111.5
Debris, and the provisions of.vIGL c 40, S 54;
Building Permit N 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 11, S 150A.
The debris will be transported by:
.ate _-r, --Z
(name ot'hauler)
I lie debris will be disposed of in
(nume of I-acilily)
(addres, ,I ljc,liiy_)
igivatwc ,f I>.•r'nut .Ipphrant
i Mute
CITY OF S.U.E1M
PUBLIC PROPERTY
DEPARTMENT
Vnroa �30 v/wvuw.�ow sn5sr•sunk •sern 01970
7tn:978-704S"• FAX 97L740.960
HOMEOWNER LICENSE EXE.MMON
Pleae Printz
Date
/ 1
Job Locstion " 7;;-F-
Home owner Address ✓ z / < T.
Home Owns Telephone ✓ /' -S-o -L
Present Mailing Address (-)err
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.
DEFINITION OF HOMEOWNER
Person(s) who oars 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 requirements.ir
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code