19 MAPLE ST - BUILDING INSPECTION (2) 1'
0a
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The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
Massachusetts Stale Building Code, 780 CMR. T"edition Building
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One. or Tiro-F nilr Duelling
,-1 This SectiQ6 F r Official Use OXY
►` Building Permit Num c 11 D APpli : C�/J /
Signature: -�`� yt-/ °2-a( 0
Building ommissione s of Buildinq L4 Date
SECTION I: 1 INFORMATION
.1 Property Address: 1.2 Assessors Map h Parcel Numbers
1q�e S+
1.1 a Is this an accepted street!yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zomng District Proposed Use Lot Area(sq R) Frontage(ft)
1.5 Building Setbacks(ft)
From Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.a0,SSe) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public O Private❑
Zone: _ Outside Flood Zane P disposal Municipal❑ On site dis sal system ❑
Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
.1 Owner'of Record:
Sus(�rl � ,IPF-F L,neho✓l � IQ McLnly sf
Name Pro �) Address fbr Service
Signs I lT Telephone
SECTION l: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Cl 1 Alteration(s) ❑ Addition O
Demolition ❑ Accessory Bldg. ❑ Number ofUniW_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Offlclal Use Only
Labor and Materials
I. Building f I. Building Permit Fee: f Indicate how fee is determined:
❑Standard City/Town Application Fee
1 Electrical f ❑Total Project Cost'(Item 6)x multiplier x
) Plumbing f 2. Other Fees: f
4. Mechanical (HVAC) S List:
5 Mechanical (Fire f Total All Fees: f
Su ression r
Check No. _Chet Amount: Cash Amount:_
6 Total Project Cost f .v(� 0 Paid in Full O Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supersisor(CSL)
L.ccma Number Espirauon Dam
N,,Ime of CSL. 1lylder List CSL Type(,cc below)
Address T Description
U Unrestricted top to 35,000 Cu. Ft.
R Restricted 1&2 Family Dviellin
Signature M masonry Only
RC Residential Roofing Coverin
Telephone ;RC
Restdennal Window and Siding
SF I Residential Solid Fuel 9u,mina Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.S 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 AfTidavil Attached? Yes .......... O 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.
;Consimclion
re of Owner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
o5ij s l) L. L,n)?Ao 4 ,as Owner or Authorized Agent hereby declare
statements and information on the foregoing application are true and accurate,to the best of my knowledge and
�'L[me �;o. wner or Authorized gentunder the sins and nalties of r uNOTES:
Owner who obtains a building permit to do his/her own work,or m owner who hires an unregistered contractor
registered in the Home Improvement Contractor(HIC)Program), will W have access to the arbitration
ram or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
struction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I 10 R6 and I IO.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/altics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halfibaths
Type of heating system Number of decks/ porches
Tv pe of cooling system Enclosed Open
3 "Total Project Square Footage"may be substituted for 'Total Project Cost"
CITY OF S.0 E-M
PUBLIC PROPERTY
DEPARTMENT
VAras 130 WAMMG roM SMUT*Susan WwaACHLWM 019-0
rai 9'8•744S"• F.%.978•740.144
HOMEOWNER LICENSE EXE.MMON
Please blot
Date
Job Location l Sf•
Home Owner Address 19 /Y)")-e St
Home Owner Telephone 4-7
S 741 q&q
cl
Present 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 acts as supervisor.
DEFINMON OF HOMEOWNER
Persons) 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 dwellin& 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 OQlciak on a form acceptable to the Building
Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeownee 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 requirsrrtents.
HOMEOWNERS SIGNATURE (//
.APPROVAL OF BUILDING INSPECTOR 4��
See other side for state code
' CITY OF SALEM
s, °\
!i PUBLIC PROPRERTY
DEPARTMENT
M .)"It - 110WASIIIN6 IONS ITLLT • SAIr\I, MASi:VA It it.Ili'J
TH:B78.74 9595 • FAX:978-740.9846
Construction Debris Disposal Affidavit
(required lur 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 c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The deb/is will be transported by:
r/ -nrn L'a.tnad
(name of hauler) _
The debris will be disposed of in
Afn-m Vie__ __
(name of fsci ity)
(address of facility) /
signs ure of permit applic nt .
c� 9-a�-o9
date