17 MALL ST - BUILDING INSPECTION (4) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
OF SALF.M
Massachusetts State Building Code, 780 CMR, 7'"edition
1 Revised Jmruury
Building Permit Application To Construct, Repair, Renovate Or Demolish a '008
One-or Two-Family Dwelling
This Section For Official Use Only
M Building Permit Number: /J Date Applied:
`f Signature: v Z /0
Building Commissioner/lnspml&4f Buildings Date
SECTION 1: SITE INFORMATION —
1.1 Property Address: �,%� 1.2 Assessors Map& Parcel Numbers
i 3 /1'/Ac� cST � � �I
L 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 11) Frontage(d)
1.5 Building Setbacks(B)
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 O On site disposal system ❑
Public❑ Private❑ al Check if es❑ P y
SECTION 2: PROPERTY OWNERSHIP'
t / 219v�n�N=RRecordL�� /�' rl7f3LG STD ,SiW4 �'l�►
V Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work': P.A70 /.!J O/1/ DO l
f ON DNE S i DE oh- TEE lisp
JSECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building S 1. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard Cityrrown Application Fee
❑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: S /AOU�i ❑Paid in Full ❑Outstanding Balance Due:
�5 Il V it'Ic la
l" � �� l (o's.Lei ,�
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
license Number Expiration Date
Name of C'SI.• I lulder
List CSL Type(see below)
rype I Description
Address +'
U Unrestricted(up to 35,000 Cu. Fl. ,
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Buming Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature 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...........13
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, , as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to w,o thorized by thiL permit application.
J Si of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I, as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are We and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of(honer or Authorized Agent Date
(Signed under the pains and penalties of perjury)
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 110.115, 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 healing 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 S.ULE.�I
PUBLIC PROPERTY
DEPARTMENT
Nnras i 3o vAouncron sn�aT•sue+a N..a�oascrn Ol9ro
TM 97a-7459S99• K%x 978-74O9e4
HOMEOWNER LICENSE EXEMPTION
Pfew Prime
Date JuL 'i 0, , 1O
Job Location /� /7fi IL, S% .
Home Owner Address . A7 r
Home Owner Telephone Oi�R — 7�l
Present Mailing Address t /yI A LG s T S�4G�r�7 t /yjft U/9
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 owns a parcel of land on whicb 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 OtHciak 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 hdshe understands the City of Salem
Building Department minimum inspection proc es and requirementsand that hdshe
will comply with said procedures and require�nt
HOMEOWNERS SIGNATURE
.APPROVAL OF BUILDENG NSPECTOR
See other side for state code
CITY OF SALEM
J_1 PUBLIC PROPRERTY
< a
DEPARTMENT
8.174;.9:95 • 1::\X: 'i'S-N 9»n
Construction Debris Disposal Affidavit
(rcxluired li)r all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 7S0 CMR section 1 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit ft _ is issued with the condition that the debris resulting front
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 transported by:
baL Seo-/7-
(name of hauler)
I he debris will be disposed of in
(name ul laal«y)
laddress ut 16iility)
�iena re of permit applicant
,late --