17 MALL ST - BUILDING INSPECTION (2) . t
'a -------- 1'he C'ununums'ealth of Massachusetts __
y, '!y Board of Building Regulations and Standards CI l'1' OF
Massachusetts State Building Code, 730 CNIR SALEM
f f Building Permit Application To Construct, Repair- Renovate Or Demolish a
One-ur Two-Fa nilr Divelline
Ufhis Section For Of • I.Jse 11
Building Permit Number: D e Applie /
Building Otlicial(Print N;unc) Signatu rle
SECTION I:SITE INFOR TI
LI Pro erty Address: 1.2 Assessors M1I & Parcel Numbers
i � mRu. ST sAc�-r✓►
I.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: I.i Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Fmmluge III)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:1M.G.1.c. 40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public�Q Private❑ 'Zone: _ Outside Flood Zone?
Chock it' e Municip" On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
ame(P rint
fait riot
N ) S1`1"Lt-r'vl f M'F} n gr9-b
Mnu, is q Nu. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction ❑ Existing Building Owner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ I Accessory Bldg. ❑ Number of Units_ Other ❑ .Specify:
Brief Description of proposed W rk':
AID Cyo0
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
It.abor and Materials) Official Use Only
I. Building S D l I. Building Permit Fee: S Indicate how fee is determined:
+. Electrical S ❑Standard City,,Town Application Fee
i, Plumbing S ❑Total Project Cost't Item 6)x multiplier _--__ x
_. Other Fees: S
1. \ledsmieal illy:\('1 S / Lisl:
9. \Iechwtical Wire S / .__--- -_----
Su i nession) ✓ 'rutai ml Fces: S
A^ Chak No. ('heck:\noutn:o. Total Project Cost: S 35oQ / --- - ---_.---
C sh Aniount:
❑ Paid in Full 13 Oulst:nding Ilul;ncc Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
I.icens¢Number -- - --' Fcptrauou Date
N:umc ol'CSI. I Iolder
List CSL 1)Ile(see heloly)
T1 PC Description
No aid Street
U l hlreslrieted(Buildings an la 15,UI10 cu. Il.l
R Restricted 1&2 Fan1il D\\clliog.
C'ilvi fowl,State.LIP %I Masonry
RC' Ro,ofing Onerin
W'S Window;uld sidinit
SF Solid Fuel Burning Appliances
1 Insulation
"fele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Registration Number Espiratiun Dale
I IIC C'onlpan) Name or I IIC Registrant Name
No. and Street Email address
City/Town.State,ZIP Teie hone
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 Affidavit Attached? Yes .......... ❑ No........... O
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.
072ei CA-Z- -
Prinl Olmer's Name(Electronic Signature) Dote
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By enter ly name below. I hereby attest under the pains and penalties of perjury that all of the information
Zcontainq i this appl'cati is true and accurate to the best of my knowledge and understanding.
er's or Aulhorirod Agent's Name Ilileclrunic Signature) Dale
NOTES:
r1l'. :An7or
btains a building permit to do his.her own work,or an owner who hires an unregistered contractor
the Home Improvement Contractor(HIC) Program).will nu have access to the arbitration
anty fund under M.G.L.c, 1q2A. Other important information on the HIC Program can be found at
v.l Information on the Construction Supervisor License can be found at
When substantial work is planned, pros ide the information below:
Total floor area(sq. ft.)_ I including garage. finished basement attics,decks or porch)
Gross living area Isy. 11.) _ _ Habitable room count
- --- ----- - -
Number of fireplaces__. Number of bedrooms -.
Numberofbathrocols Numberoflialfhatlis _.. ._.
I's Ile of heating system Number of decks, porches
1'1 Ile of cOUllllg i)ilelll _ _ _ _ 1,I1cloied , _ .__ _ --Open
� I
.1. -folal Project Square Footage-nlav he substituted l'or-Folul Project Cost-
e
CITY OF S.U.E.tit
PUBLIC PROPERTY
DEPARTMENT
w.
w.ae 130 wASW AGRN anaar•&#Amkt%UMA0a earn 019-0
ftrL 9-6-74.95" F.As 9-8.740.9W
HOMEOWNER LICENSE EXE.NM10N
Pkaw Font
Dat. qltqlgoll
lob Location l
Home Owner Address
Home Owner?elepbone
Presort Mailing Address
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 seta as supervisor.
DFYIN ION OF HOMEOWNER
Petson(s) who owns a pared of land on which he/she resides or intends to resider on
which chars is, or is intended to bs, a one or two family dweWag, 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
"lwmeowner"shall submit to the Building O®ei4 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 reguladonL
The undersigned "homeowner'certifies that hdshe understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and roqui�
HOJgEOWNERS SIGNATL72 �
APPROVAL OF BUILDING INSPECTOR
Sea other side for state code
CITY OF AASSACHL'SETTS
13umDLYG 0EP.1RTtENT
120 W-ksm C4GTON STURT, Yo FLOOR
TLL (978) 745.9595
KI BERMY DRLSCOLL FAX(978) 740-9846
,MAYOR T)fom"ST.Pmmx
DIREc rozOpPLsucPROPERTY/acamLNGGONOUSS[ONER
Construction Debris Disposal AlVdavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section I 11.5
Debris, and the provisions of M_ GL c 40, S 54;
Building Permit M is issued with the condition that the debris resulting ftom
this work shall be disposed of in a properly licensed waste disposal facility as defined by NIGL c
111. S 150A.
The debris will be transported by:
OAIY
(name of howler)
The debris wi If be disposed of in :
(name of facjl )
(addrta�of facihtY) �
elynamre of permit applicant
Mate
: �n vd I,ti