32 MARLBOROUGH RD - BUILDING INSPECTION The Commonwealth of Massachusetts
qh. Board of Building Regulations and St it arcMV AL S-RVi OF
�'7 1 Massachusetts State Building Code, 780 CMR N SALEM
Building Permit Application To Construct, Repair, Renovate(94�[�c'fYdlis�a
One-or Two-Farnily Dwelling
This Section For Official Use Only
Building Permit Number: D.to Ap 'ed:
E / l
Building Official(Print Name) Signature D• e
SECTION I:SITE INFORMATI N
1.1 Properly Address: 1.2 Assessors Map& Parcel Numbers
1.1 a Is this an accepted street?y+ s no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Prolxhscd Use Lol Area(sq 11) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
___+1.6 Water Supply:(ivLG.L c.40,§54) 1.7 Flood Zone Information: I.8 Sewage Disposal System:
Public Private❑ Zono: _ Outside flood Loney
Check ifyes❑ Municipal ❑ On site disposal system ❑
SECTION2: PROPERTYOWNERSIIIPt
2.1 Owner'of Record:
_i9i mm,t)i�2Lc _ S LY MA 017 70
Name(Print) /n�(� City,State,ZIP
V" l&I-913 - 95/J Ll L'RTy� l: aU1 v�tNt
No.and StrmlU Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building m- Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) le Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':^,
o
SECTION 4: ESTfiNIATF,D CONSTRUCTION COST-sr
Item Estimated Costs:
(Labor and Materials) Official Use Only
1. Building $ 1. Building Permit Fee:$ _Indicate how fee is determined:
2. _,,lectrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier_ x
3. Plumbing $ 2. Other Fees: $_
4. Mechanical (I IVAC) $ List:_
5. Mechanical (Fire
Su h)ression) $ Total All Fees: $_
6. Total Project Cost: S
Check No.--
-Check Amount Cash AmounC
Sn�
✓�V ❑ Paid in Full ❑ Outstanding Balance Due:
(/,)N e-t,3 V-e-p<o 9
.:rx(.ue;o to 1 Z 3 y V 0 .
„ SECTION 5: CONSTRUCTION SERVICES
5.1 Cgnstruction'IS i'ervisor License(CSL) 1
License Number Expiration Date
Name%, CSL Holder,' ' ) u!h ;,.�CL 'dS List CSI,.Type(see below)
No.and Street 'type Description
U Unrestricted(Buildings up to 35,000 cu. 11.)
R Restricted M2 Family Dwelling
CityfFown,Slate,ZIP M Mason
ry
RC Roofing Covering
WS Windowand Siding
SF Solid Fuel Burning Appliemces
1 Insulation
Telephone Email address D Demolition
5.2 Registered dome Improvement Contractor(HIC)
I11C Registration Number Expiration Date
HIC Company Name or IiIC Rcgistr:mt Name
No.and Street
Email address
City/Town, State,ZIP Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(iNI.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........... 0
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 Nome(Elect Signature) Date
SECTION 7b: OWNEW 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.
Print Owner's or Authorize< nt's Name(Electronic Si hat tr 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.nwss._rov/oca Information on the Construction Supervisor License can be found at www.nt SS.tov/dps
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. R.) Habitable room count _
Number of fireplaces Number of bedrooms
Number of bathrooms_ Number of half/baths
Type of heating system Number of decks/porches_
Typeofcoolingsystem _ Enclosed Open
3. Total Project Square Footage”may be substituted for"Total Project Cost"
CITY OF SALEM, MASSACHUSETTS
^ � BUILDING DEPARTMENT
120 WASHINGTONSTREET,YD FLOOR
`P nrsp TEL. (978) 745-9595
FAX(978) 740-9846
KINIBERLEY DRISCOLL
MAYOR THomAs STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date 6 " 1 7 " /�
Job Location 1500'm(�� Kd�Q Sa1�1M f lq 01 70
Home Owner Address SG1 VV\L
Present Mailing Address bC1,Wl�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
isJintended 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 .l7'VIY,I s
APPROVAL OF BUILDING INSPECTOR
Li' tt CITY OF SM E,b[, 1%CASSACI-IUSETTS
E1L'ILDLNG DEP.IRTJIEYT
130 CV.hHLNGTON STREET, 3w FLOOR
T�L (973) 745-9595
KIMSERLEY DIMSCOLL RUX(973) 740-934,5
N&kyoa
I'-iOJGLB ST.P1E.71t$
D UCrOR OF PUBLIC PROPER7y/8CU_0LYG COSLNUSSIONER
Construction Debris Disposal Arf1davit
(required for all demolition ;md.renovation work)
In accordance tivith the sixth edition of the State Building Coda, 730 CMR section I
Debris, vtd die provisions of MGL e 40, S 54;
11 Building Permit d is issued with the condition that the debris resulting from
work shall be liisposcd of in a properly licensed wasta disposal facility yy dafincd by S4CL c
1
I I, S ISOA.
The debris will berrtr''a1nsportcd by:
(namcuflta )
The dchris wi11 be disposed ot'in
Nc h ShoVe Lcr f,
(name of lacdity) ��
_---_—I Idres.1 or tacilil�)
ognanue Xp,:, it I p(, a
62=L7