83 LINDEN ST - BUILDING INSPECTION y
The Commonwealth of Massachusetts CI"I'ti'OF
Board of Building Regulations and St' Bards SALEM
o Massachusetts St Building Code, 78 CMR
Keri.ved I for 2011
L„N
Building Permit Application T Co stntct, Repair, cnovate Or Demolish a
One-or Two Family Dice( ng
"Phis ecti n For Of7ic' Use Onl
Building Permit Number: Dal Applied:
G {o. 20 11
Building OlTicial(Print Name Signature Date
SECTION I SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
A� L ZQ(1) e t4 IS R
I.l a Is�an accepted street?yes_ no_ Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning Di tncl Proposed Use Lot Aroa(sq It) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Require=d = Provided Required Provided Required Provided
L6 Water Supply:(M.G.1.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ n s disposals)On dis s stem ElPublic ❑ Private❑ Check if yes❑ P P F
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record• tJYY(.
MA , M v /A a,/ _� IV
Name(Print) , City,State.ZIP
8 � L � N1��� R78- 7 -Z5hl
No.and Street Telephone Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ 1 Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
e f S !
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building $ 1. Building Permit Fee: $ indicate how fee is determined:
❑Standard City/Town Application Fee
'_. Electrical $ ❑Total Project Costr(Item 6)x multiplier x j
i. Plumbing $ 2. Other Fees: $
4. Mechanical (UVAC) $ List:
i. .\Icclmlcal (Fire g Total All Fees: $ -- -
tiu. xessionl —
a D Check No._Check Amount: __—Cash Amount:___
/ 6. Total Project Cost: $ 200 0 paid in Full 0 Outstanding Balance Due: _
r
SECTION 5: CONST'RUC'FION SERVICES
5.1 Construction Supervisor License(CSL)
.._ License Nunmbcr lispiralion Dale
N;unc of C'Sl. I IolJer '
List CSL'I'ype(see below) _
Nu.and Slrcet — -- Type Description
U Ilnrestrieted(BuilJin�s u' to 35,000 cu. ft.)
Citylfown.State,ZIP R Restricted I&2 Fan.il n---n;n
M Masunr
RC Roolin Covering
WS Window and—'
SF Solid Fuel Burning Appliances j
_ I Insulation
'I'c1e hone F.mail address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or I IIC Registrant Name I IIC--- .;uion Numher Expiration Date
No. and Street
Email address
Ci /Town, State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 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
I, 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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
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 a curate to the best of my knowledge and understanding. II
P . Oils ner's or A; razed Agent's Name(Electronic Signature) ?/��e 4�
Date
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 Hume Improvement Contractor(HIC) Program),will not have access to the arbitration
program or guaranty fund under I.G.L.c. 1-{_'A.Other important information on the HIC Program can be found at
%~\,ola iN hoc oca Information on the Construction Supervisor License can be found at cn�v�o iicu:.yin-,11m,
1V2.
hen substantial work is planned, provide the information below:
Total flour area(sq. ft.) _(including garage, finished basement'attics,decks or porch)
Gross living area(sq. Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms
Number of halfbaths
I v pc of heating syswnm - --
__..-_-------_--- Number of decks, porch—es
T)pe of cooling s)stem
._..__. --- ------ Gmcloscd ---Open
3. ''Lulal Project Square Footage"ilia) be substilmed air total Project Cost'
CITY OF S�U-&NI, A%L1SS.,CHL'SETI S
13uLwLNG DEPARTNONT
120 WALSHLNGTON STREET, 3i0 FLOOR
TEL (978) 745-959S
PAX(978) 740-980
KIJBERLEY DRLSCOLL
MAYOR THo.�tns ST.Pmnz
DIREcroR OP pLBLic PROPERTY/HCILDLNG COMMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 1 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit q is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defincd by MGL c
l 11, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in : (� `� 0(1— D
(name of facility)
(address of facility)
�signa.tu}.r1f p rmit applicant
date
la M1rwif,bx
CITY OF S UX.NI
PUBLIC PROPERTY
DEPARTMENT
Kl10kYaY D�i'w
Vwroa IbWA"MGTMsnesr•1uiteNUUMMMMe1r0
M.rs.r+s.ssn •t..r rs.»e.ew
HOMEOWNER LIMNSE EXEMPTION
Pkaw hint
Dats to-Z- 1 I
Job Locatics 8 3 L /M.0 E7A1 SY-- 2a b_ M
Home Owns Address
Home Owns Telephone 9 7 R— 74 SL-- ge S(,
Present hssiling Address S-, "LQ—
TIM 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 owns acts as supervisor.
DEFINITION OF HOMWWNEJt
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 dwelUnS 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.
HOMEOWNERS SIGNAMRE �qult A
APPROVAL OF BUILDING DiSPECTOR
See other side for state code