112 MARGIN ST - BUILDING INSPECTION (3) The Commonwealth of Nlassachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CNIR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
r1f► One- or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: .
r ;
N�utldtrig Official(Print Name) Tignatq. Date
SECTION E SITE INFORb O
(y 1.1 Property Address: 1.2 Assesso ap& Parcel Numbers
112 Lrn onG.-
1.l 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 ft) Frontage(ft)
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.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2:, PROPERTY OWNERSHIP"'
2.1 Owneri of Record:
n��a ford: �r 4n1ern ma. (Dlq0�
Name(Print) City,State,ZIP
No. and Street 7 Telephone Email A8dregs
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building ❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work: h
x S e,
\ SECTION 4: ESTINIATED CONSTRUCTION COSTS-.
Item Estimated Costs: Official Use Only_
Labor and Nfaterials y' .,
I. Building $ I. Building Permit Fee $1 Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total project Cost',(ltem.6)x multiplier x
3. Plumbing S 2.1 Other Fees: $ 1 �'
1. Mechanical (HVAC) $ List: / �/ rCA
14
i. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount-.
6. "Total Project Cost S /$^00 0 Paid in Full Cl Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES I
5.1 Consh action Supervisor License(CSL)
License Number Expiration Date
Name of CSL I(older
List CSL Type(see below)
X Type Description
No. and Street
U Unrestricted Buildin s up to 35,000 cu. ft.)
_ R Restricted 1&2 Family Dwelling
City/Town, State, ZIP a VI 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(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/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
1, 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: OWNER' 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.
n A n e l� (Y) p 7 n c)c,�= — L- 9 - @013
Print Owner's or Authorized Agent's Nane(Electronic Signature) Date
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 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
wwW.mass."Ov/ocn Information on the Construction Supervisor License can be found at www.rnass._u�s41L
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.) _(including garage, tinislied basement/attics,decks or porch)
Gross living urea(sq. ft.) _ _ Habitable room count
Number of fitePlaces Number ofbadrooms - --_
Number of hathroorts Number of half/baths
rype of heating system Number of decks/porches
I'ypeOr Cooling sy;ion_ _ Enclosed-- _Open
_i. `' fetal Project tiqunre Footn��c" stay bu sub,tihrted t�a"'futnl Project Cost"
- 1
"r CITY OF SALEM, UxsSACHUSE-M
t BuiLDNG DEPARTNIENT
120%V.1sHLNGTON STREET, 3"a Room
T EL (978) 745-9595
R+s(978) 740-9846
KI.Nf3ERL.EY DRISCOLL
NL-%YOR T1 io.%w ST.PtERRH
DIRECTOR OF PUBLIC PROPERTY/SUILDNG CONL\IISSIONER
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 11 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit It is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by NiGL c
111, S 150A.
The debris will be transported by:
(name of liauler)
The debris will be disposed of in
_--- (name of facility)
(address of facility)
�1pJyl m can ® �k
signature of permit applicant
q —e,?o
date
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lid CITY OF S.U..E.%f
PUBLIC PROPERTY
DEPARTMENT
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HOMEOWNER LICENSB EXE.MMOV
P1eaw IMet
Dat. � 4 13
Job Location Stqme. /Zc be (bc
Home Owoes Address 1 12 Mci-A,n t, o-rvv /Y1 a 'r I a
Home Owow Telephone Cj2V 2 LA Lf s-4 �--A IS Co
Present Mailing Address---CPyexp , -CQ--L U4
The current exemption of"Homeowners"was extended to include ownw-occupied
dwellings of two Units or teas and to allow such homeowners to engage m individual for
hire who.does not possess a iicau%provided that the owner acts as superviaw.
DEFINITION OF HOMEOWNER
Persons) who owns a pared of tow on which bdshe resider or Interde to resider,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 pawn who constructs more
than one home in a two year period shall not be considered a homeowner: Such
"homeowner'shall submit to the Building Omeial,on a fors 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 bylaws and reguladonL
The undersigned "homeowner"certifies that he/she understands the City of Salem
E3WIding Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF SUILDLYG NSPECTO
J
Sce other side far state code