36 MARLBOROUGH RD - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
— - Board of Building Regulations and Standards CITY
t Massachusetts State Building Code, 780 CMR, 7ih edition OF SALEM
Bruised Januury
'4?�0
1 1 Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, 2008
\\{^) One-or Two-F mi4y Dwelling
n This Sec on n For Official Use Only
Y I Building Permit Number: Date Applied: J J !
71
Signature: �J
Building ommissioner/fnsFVor of Buildings Date
SECTION I:SITE INFORMATION
1.1 1 pe Addres : 1.2 Assessors Map& Parcel Numbers
X � l�rty/Cf/'/�Ya[L�sl� � -
I.Ia Is this an accepted streeC?yes no o Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sy 11) 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 Owner`of Record: /
/'e✓i ) I/eirof7`c ,3G /"19 -�L.- o -q4 �"f
�( NaT;(Print) Address for Service:
D7r 7y1 et1J' ?
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Cl Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
K /u mow, noon
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Offleial Use Only
Labor and Materials
I. Building S I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
1 Plumbing S 2. Other Fees: $
4. Mechanical (IIVAC) S List:
'/ 5. Mechanical (Fire $
7t Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount
6.ryTotal Project Cost: $1 O 0 Paid
,iinn Full ., ❑ Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL-I folder List CSL type(see below)
Tv a Description
Address li Unrestricted(up to 35,000 Cu. Ft.)
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC Residential Rooting Covering
'Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or HIC Registrant Name Registration Number J
Address
Expiration Date
Signature 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.
Signature of Owner Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
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.
c,/ //L-
Print Nam, //
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.115, respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"
CITY OF S.U.EM
PUBLIC PROPERTY
DEPARTMENT
u.u.s.o�suatL
Vwvae I30WASMOG eNSMEW•3A1aq VAaAO&SIM411'0
HOMEOWNER LICENSE EXEMPTION
P1eue hint
Date /i / -7 v
Job Locados
Home Owner Address EA rn-z
Homo Owner TekpI
Ptese@t Mailing Alien jqm-e
The current exemption of"Homeownere we@ extended to include owner-occupied
dwellings of two Unite or lose and to allow such homeowners to eapapa an individual for
hire who.does not possess;a licaos4 provided that the owner acts as supervisor.
DEF NM0N OF HOMEOWNEX
Perso s who owns a of land on which hdshe re@ida a n( ) parcel iatmda to reside6 on
which there is, or is intended to bs4 a one or two hmdy dwelling,attached or detached
structures accessory to such use and/or fam structure& A person who constnrcu more
than one home in a two year period shall not be considered a homeowner. Such
s tomeownd'sW submit to the Building O®cial,on a form acceptable to the Building
Official, that Wshe be responsible for all such wort performed under the Building
PermiL
The undersigned "homeowner"assume@ responsibility for compliance with the State
Building Code and other applicable bylaws and reg ladons.
The undersigned "homeowner"certifies that he/she understands the City of Salem
Buiidin j Department minimum inspection procedures and requirements and that hNshe
Will comply with said procedures and requimnents.
HOMEOWNERS SIGNATLRE
.APPROVAL OF SUILDNG NSPECTOR
See other side for state code
CITY OF S.UE.Nf, NL-kss.AaiUSETI'S
• BI;ILDLNG DEPARTMENT
130 WASHmi;TON STREET, 3iO FLOOR
TM (978) 745-959S
FAX(978) 740-9846
KIJf$E U.EY DRISCOLL
,MAYOR THOatnsST.PtERRs
r DIRECTOR OF PuaLic PROPERTY/HCR.DLNG co.%z tsstOYER
r
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 I 11.5
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 be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(nameaf hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit applicant
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