18 MANNING ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 730 CMR Revired,tJar 201!
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only '
Building Permit Number: A lied
Dl-
7—
Duilding Official(Pont Name). Signs Date
SECTION l:SITE FOWNIATION`
I. Property Address: 1.2 Assessors,�lap&Parcel Numbers
A n.2
„t 1V
I.I a Is this an accepted treet7 yes no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yams Rear Yard
=WaterSupply:
Provided Required Provided Required Provided
(M.G.L c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood ZoneiMunicipal 0 On site disposal system ❑
❑ Cheek if es❑SECTION2: PROPERTY OWNERSHIP!:
uord: ( l,U 11
i�tlme(Print) City,State,ZIP
jCU371%
14S /h�qa � -
No.and Street _J Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑- Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Spedly:
Brief Description of Proposed Work': o w Lon o %e Cx sh' i n c
r. , ✓ t�
J .
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Ofticirl Use Only
Labor and Materials
1. Building $ I. Building Permit Fee:$ Indicate how fee is determined:
❑StanJard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S i%9ther Fees: S
d.�Xlech:mical (HVAC) S List:
5. Mechanical (Fire S 'total All Fees:S
Suppression)
G Check No. Check Amount: Cash Amount:
6.'rutal Project Cult S JC X�� ❑Paid in Full (3 Outstanding Balance Due:
t " <
SECTION 5: CONSTRUCTION SERVICES
5.1 Cortstructimt Supervisor License(CSL)
License Number Expiration Dale
Name of CSL Holder List CSL"type(see belmv)
No. and Street
Type Description
U Unrestricted((Buildings Lip to 35A00 cu. It.)
R Restricted 1&2 Family Dwelling
City/Futvn,State,"LIP _ M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Slrcet Email address
City/Town, State ZIP Tele hone
SECTION 6:WORKERS'CONIPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 2$C(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 Ishuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No...........❑
SECTION 7a:OWNER AUTHORIZATION.TO BE COMPLETED WHEN. i-
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Nane(Electronic Signature) Date
SECTION 7b:OWNER[OR AUTHORIZED AGENT DECLARATION
By entering my name below, t hereby attest under the pains and penalties of perjury that all of the information
conta�t this�pcati `` true and ccurate to the best of my knowledge and understanding. .
��l 1X _Z1Z 3�J J
"rfiiFOwn 's- tlfrizedt's Name(Elcctrome Signature) Date
NOTES:
1. 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 nnr have access to the arbitration
program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program can be found at
www m:as_�ov'oca Information on the Construction Supervisor License can be round at www.mas.�wv'dy__Lu .
2. When substantial work is planned, provide the information below:
'total fluor area(sq. ft.) .(including garage, finished basementlattics,decks or porch)
Gross living area(sq. R.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of hcnting system Number of decks/porches
'type of cooling system Enclosed Open_
1. "Total Project Square Footage"may be substituted for-rotal Project Cost"
QTY OF SALEM) MASSACHUSE M
BUILDING DEPARTMENT
r c_ 120 WASHNGTON STREET,3R0 FLOOR
TtJ- (978)745-9595
KIMBERLEYDRISCOL.L FAX(978)740-9846
MAYOR THOMAS ST.PIERRE
DIRECTOR OFPUBUCPROPERTY/BUI DDING 00AIMSSIONER
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 111.5 Debris,
and the provisions of MGL c40, S 54; Building Permit # is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined b MGL c 11 1 Y , S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
l e
(address of facility)
/y/L
Signature of applicant
lZ�Z3�i�
Date
CITY OF SALEM, MASSAC IUSETTS
BUILDING DEPARTMENT
120WASHNGTON STREET,3RO FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KINMERLEY DRISCOLL
MAYOR THOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date /Z/ '23/`1i \
Job Location ! O /�I� ;, ej S 51,
r
Home Owner Address r
Present Mailing Address St
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 that does not possess a
license, provided that the owner acts as supervisor.
DEFINITION 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 understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE.—
APPROVAL OF BUILDIN(` SPECTOR /Zz 3 1Z/S�