17 MALL ST - BUILDING INSPECTION (3) n
Q The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
� Massachusetts State Building Code, 780 CMR, Vh edition t� Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a *kvomwkvoj
One- or Ato-Funtih•Dwelling
1 This Section For Official Use Only
—� Building Permit Number: Date Applied: t U q
Signature: s U I
Bwldin Commissioner/ Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
/4f1LL �
1.1 a 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(it)
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.a0,lSa) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Munici al On site disposal system ❑
Public Private❑ Check if es P Po Y
SECTION 2: PROPERTY OWNERSHIP'
2.1 4 ner o'Teco �
N� 1 int) �F/J Address for Service:
97� - 7XJ--136
S gnature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑ I,
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify:
Brief De rp'ion of Proposed Work': HC b T& D c$/ /
p LACe F20A/ UO
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: ORlclal Use Only
Labor and Materials
I. Building $ I 0, ' 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
J. Plumbing $ 2. Other Fees: S
4. .Mechanical tHVAC) S List:
S Mechanical (Fire S Total All Fees: S
Su ression
Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: f ` Off, 0 Paid in Full 0 Outstanding Balance Due:
R
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
t.
• Linnse Numhr E.apirmion Date
N;)me of CSL Helder List CSL Type(sec below)
T Description
Address
U Unrestricted(up to 33,000 Cu. Ft.)
R Restricted 1&2 Family Dwelling
Signature .M Masainry Only
RC Rcstdcnnal Rmfin Coverin
Telephone WS Resdenual Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
' HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Dale
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 2SC(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.......... O No...........❑
SECTION 7s: 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.
Si nature of Owner Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
(, /;/2��v0/� (fin V�— ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
beh 'r42F
Print Name
Signature of Owner or Authorized Agent Date
Si tied under the pains and penalties ofperjury)
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 W have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS,respectively.
2. When substantial work is planned,provide the information below:
Total Ooors 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
Ty pe of cooling system Enclosed Open
1. "Total Project Square Footage"may he suhstituted for 'Total Project Cost'
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
Vwva� 1309rAweurrow SUM 9 SAL 4wtrAaas6r1s01970
7VL 971•74195"9 Fnx.978.7.1&9&W
HOMEOWNER LICENSE EXEIMMON
Please"t
Date 7 9 0
Job Location /'nf}GG <ST , SfIZ�✓rt
Home Owner Address
Home Owner Telephone
Present Mailing Addrw / /y/ff Lc S 7-
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.
DEFINMON OF HOMEOWNER
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 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 r r t.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SALEM
; ��s , , PUBLIC PROPRERTY
4
DEPARTMENT
Construction Debris Disposal Allidavit
oc\luircd li)r all demolition and rcllo%miun work)
In accurdance \\ith the sixth edition of the State Building Code, 7SO CAIR section 1 1 1.5
Dcbris, and the provisions of IGL c 40, S 54;
Building Permit N is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I1I. S 150A.
The debris will be transported by;
Q rL � sCoT1
owrnc Of huJcr)
I lie debris will be disposed ofin
t name of laahty)
(,otfrei. r)l IJc Joy) J
. �n Ime of pctnul .y+phrant
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