17 MARLBOROUGH ROAD - B-11-426 SHED J
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IThe Cummonwcalth of Massachuscros *600ow"M
y f + Board of Building Regulations and Standards
V11�1I 1y �� Massachusetts State Building Code, 780 CMR, 7'"edition Building
Building Permit Appf ation To Construct. Rep u. Renovate Or Demolish
UUU1 e- orTuwFaind selling
This Section F -cial Use Only
Building Permit u r: Date Applied: to
Signature:
Building Commissioner/Ins or of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Propert� d sa: o r �� _ / 1.2 Assessors Map& Parcel Number
I.1 a Is this an accepted street?yea no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning Disinct Proposed Use Lot Area(sq n) Frontage(n)
1.5 Building Setbacks(R)
Front Yard Side Yards Rev Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1,c. 40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zags?
Public Private Check if esO� Municipal�n site disposal system 0
SECTION 2: PROPERTY OWNERSHIP'
Owner'of or /qe l
r ►Ma e/C !r Maw l bo sw��. O� . �+/�, 6 97a
me int) JAddress for Service:
I H - )"K - 101/b
signature ITelephone
SECTION l: DESCRIPTION OF PROPOSED WORK (chock all that apply)
New Construction Existing Building O 1 Owner-Occupied O Repairs(s) O 1 Alteration(s) O Addition O
Demolition 0 1 Accessory Bldg.&I Number of Units_ I Other O Specify:
Brief Description of Proposed Works: Cee S+A,0&�g SheAS i
ii
�M C2M aoJ" �)ec�C
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building 0 I. Building Permit Fee: f Indicate how fee is determined:
❑Standard City/Town Application Fee
2 Electrical S O Total Project Costs(Item 6)x multiplier x
J Plumbing S 2. Other Fees: S
a. Mechanical (HVAC) S List:
s Mechanical (Fire S Total All fees: S i f >
Surinsession
Check No. _Check Amount: Cash Amount.
6 Total Project Cost: S fro Oa7 ❑ Paid in Full 0 Ountanding Balance Due:
l
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
'• I
e NumRr Esptranon Date
Nyae ul l SL- Hplder SL Type Ix;e heluw)
Description
Addrrss Unrestricted u to 35.000 Cu. Ft.
Restricted Ik2 Fam l DwellmSianamre Mawn Only
RC Residential Roofing Covering
Telephone w'S RestJential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D I 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.c. 152.§ ISC(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.......... O No........... O
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.
Si nature of Owner Date
( SECGTION 7b( NN:OWNER'OR AUTHORIZED AGENT DECLARATION
:S • C h ruS71t ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf. �� p ,
' )<4✓J G eea. S . (fit aw4�'�
Print N
Signature of Owner or Authorized Agent Date
(Signed under the orains and penalties ofperjury)
NOTES:
Fof
wner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractorregistered in the Home Improvement Contractor(HIC)Program), will gg have access to the arbitrationam or guaranty Fund under M.G.L. c. 142A. Other important information on the HIC Program and
truction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110 R6 and 110.RS, respectively.substantial work is planned,provide the information belowrs area(Sq. FL) (including garage, finished basementlattics,decks or porch►ng area(Sq. Ft.) Habitable room count
f rreplaces Number of bedrooms
bathrooms Number of half.baths
Type of hearing system Number of decks/ porches
Ty pc ofcoobng system Enclosed Open
1 ' Total Project Square Footage"may he substituted for 'Total Projecl Cost"
CITY OF SM.E.M
PUBLIC PROPERTY
DEPARntENT
w.a.,.s*�+ �3a vtr�wwcrou sneer•su.ra Nws�oasam Ot fro
17L 97f7l17S!! • F.aL 9'L7JG9W
HOMEOWNER LICENSE EXE.r[MON
Pkage trt.t
Job Location M° l6vxcw5 ` 5A/ /i'1a 0� 9
Home Owner Address
Home Owner Telephone 3 -
Present Mailing Address S A-m P
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or leas and to glow such homeowners to eagage an individual for
hire who does not posam a lcena0.provided that the owner acts as supervisor.
DEFiNMON 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 dwellin& attached or detached
structure accessory to each 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"assumed 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 requirements.
HOyIEOWNERS SIGNATL
,- PPROVAL OF BUILDING INSPECTOR
See other side for state code
1
CITY OF SALEM
�a•
PUBLIC PROPRERTY
• , �/ DEPARTMENT
Pdl:: 81 h1 ' Nlw r'd1
µkl'T 0 S.\I Pf1. M.Ni.\l
979-740-9446
Construction Debris Disposal Affidavit
(required 1'ur all demolition and renovation work) .
In accordance with the sixth edition of the State Building Code, 780 CINR 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
I 11. S 150A.
The debris will be transported by:<--RPf.eeCA C��S�1Q /N `P �- a"-4c reS
(name of hauler)
The debris will be disposed of in
/�ax't� �tdc �a��✓� ,
plame�r anti nr)
w•a Ac(Xco `� 5'+f t • IMo 01
laddrcxs of tardily)
r
.ignaturc of(xnnit� dice t
date
tani•�I(dm