1 MAPLE ST - BUILDING INSPECTION � O9 I
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� The Commonwealth ofMassachusetts RECEtVED
.� '� Boazd ofBuilding Regulations and Standazds INSPE TIO?'�lT_�uiC S
Massachusetts State Building Code, 780 CMR SALEM
Revised Mqr 2��1 1
� Building Permit Application To Construct,Repair,Renovate Or Demolis��5 UL I 3 H
9 One-or Two-Family Dwelling
, '17tis Section Fo�Official Use Only
� ' n Building Permit I�fum6er. � � ��Date Applied: . .. .
U1 . . :. . . . .
� a. . ..F } �'�.
1 � Bmldiug O#ficial(PrintName) . � ��Sigiatw�e � � Date
� SECTION 1:SITE INFORMATiON
- � 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1 McLp1e, SF.
11a 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 ft) Frontage(ft)
1.5 Building Setbacks(ft)
Fron[Yard Side Yards Reaz Yazd
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.4Q§54) 1.7 Flood Zone Informafion: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑
Check if yesO
+ SECT[03V2: pR01'�ItTl'OWN�RSHfFi . =
2.1 Owner�of Record: � �
Er;c a�a �1oe��}.��\a;re� Sa1Cm , IYIA _ 0l9"10
Narne(Print) City,State,ZIP
I Manle Sk. 9�-5q4-83u�
No.and Street Telephone Emai]Address
SECTION 3:DESCRIPTIDN OF PROPQSED WORICZ(e6eck a11 that apply)=''
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: �
Brief Description of Proposed WorlcZ: rQC "(� n X 1 e�
SECTION 4:ESTIMATED CONSTRUCTIDN COSTS
Item Estimated Costs: Official Use Only
abor and Materials - �
1.Building $ 1. Buildtng Pem�it Feei$ . Indicate hotiv fee is determined:
2.Electrical $ ����d City/1'o�vn Application Fee
❑Tofa1 Project Cost}.(Item 6)x aiultiplier x
3.Plumbing S 2. OtherFees; $
4.Mechanical (I-IVAC) $ .List; � ' �
5.Mechanical (Fire $ �- .. . . . .. � .
Su ression Total All Fees:$ . �
Check No. � �Cheek Amount: Cash Amount '
.� 6.Tatal Project Cost: $ 3��g�-� p Paid inFutl ❑Outs4a�dingBalanceDue:
S�-r -�� ri -o - � 1 ��
SECTION 5s CONSTRUCTION SERVICES y
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(RIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
Ci /Town State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c..152.§ 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:OWNERr 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 accurate to the best of my knowledge and understanding.
i iloe1 S Mu, fe j 7 13�IS
Print Owner's or Authorized Agent's Name(Electronic 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 not 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
xitivw:mass, og v,%oca Information on the Construction Supervisor License can be found at ww�i.mass.eov/dns
2. When substantial work is planned,provide the information below:
Total floor 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
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
QTY OF SALEM, MASSACHUSE TTS
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BUILDINGDEPARTMENr
120 WASHINGTON STREET,3" FLOOR
TEL. (978)745-9595
F
KIMBERLEYDRISCOLL FAX(978)740-9846
MAYOR THomm STTIERRE
DIRECTOR OFPUBLICPROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date \
Job Location Male s�. SQker,, } (Y)n . 01 10
Home Owner Address ma-&- S�II. SC IP,m ; MA . of R-70
Present Mailing Address on, o\C)--?Q
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 Y 1 a_ck I'M t�Lt tk
APPROVAL OF BUILDING INSPECTOR
a MORTGAGE INSPECTION
BAY STATE SURVEYING ASSOCIATES INC. JOB#tijQ jQ
100 CUMMINGS CENTER,SUITE#316J
BEVERLY,MA.,01915-5795
LOCATION:.L4 MR ...._._...........,. NOTA
1)Thls Is a mortgage impact[=survey and not an
I_ I S ..•......•.' Instrument survey,therefore this plat Plan la for
SCALE:1"=zb'DATE:_.,........._-...._....._. mortgage inspection purposes any."is NOT to
be used to establish boundaries or for the
REFERENCE: 6K,3Iy4 PG:)ZZ rty cotmtruction of atype of improvements. _
. . 2)This Survey ts based on survey marks of Whom
.. X —m.. .G . 3)Bush W.shrubs,fences and tree three,do not
necessarily...........{. M4.-!`5a............. necessarily Indicate,property hes.
o
.4)Whenever an offset is 11. or less,an Instrument
TO:.srt!4 !�.� FIVE MOx?G�9GF „_.,,,,,,, sunny Is recommended to determine property
....._._. lines,and a
The location of the bullding(s)as shown,either any possible encroachments.
an a
enmpned with the local zoning setbacks m the time of G Offsets shown are or the determination
and are to be
oonatruction oris "emptfrom violation enforcement Used used to
establish rmiretlon Mzonine,Not to
action under Mass.G.L.THIS VIIChapterQA Section? n usedfenstsbil opinion
property Imes.
In at professional the special
opinion Ae building(,)are not
!scaled b the special flood haeN zone,as
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