75 MARLBOROUGH RD - BUILDING INSPECTION Tb— lq-- i -7Z3
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
N bft;/ Massachusetts State Building Code, 780 CNIR Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Fnmily DiveUing
This Section For Official Use Only
DateA pp lied-
Building Permit Number:
ignature Datr�
Building Olticial(Print Name). m
SECTION t:SITE INFORtNIATION n
1. Property Address: 1.2 Assessors Map& Parcel Numbers —r
hb >•da.r(boUmw�t Map R�
I-/ m
I.la Is this an accepted street?yes_ no_ P Nwnber Parcel Number CD
1.3 Zoning Information: 1.4 Property Dimensions: om
Zoning District Proposed Use Lot Area(sy It) Frontagel)(I
1.5 Building Setbacks(R)
Front Yard
Side Yards Rear Yard
Reyuircd Provided Required Provided Required Provided
1.6\Voter Supply:(M.G.L c.J0,§Sy) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal [3 On site disposal system ❑
Public❑ Private❑ Check if es❑
SECTION2. PROPERTY OWNERSHIP"
2.1 Ow ert of Recor
`Lug,; "(
�me(Print) City,State,ZIP
Nu. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ INwnber of Units_ I Other ❑ Specify:
Brief D scription of Proposed Work':
�l(\l S�1Ril, �RS�rrnnnf�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Itcm Labor and Materials)
I. Building S I. Building Permit Fee:S Indicate now fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Costa(item 6)s multiplier s
3. Plumbing S 2' Other Fees: .5
t. Mechanical (11VAC) S List:
5. Mechanical (Fire 5 Total All Fees: S
Suppression)
Check No. Check Amount: Cash Amount:
6. Total Project Cost: 5 brim- , 61) ❑ Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Coustruction Supervisor License(CSL)
License Number Expiration Dale
Name of CSL Holder
List CSL'type(see below)
No. and Street Type Description
U Unrestricted(Buildings tip-to 35,000 cu. 11.
R Restricted 1&2 Family Dwelling
Cityll'own,State,ZIP iVl Nllsonry
,y RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
'rcle hone 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 Istuance 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'
I, as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's N:une(Electronic Signature) Date
SECTION 7b:ONNEW 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"V"`V,� � �is true and accurate to the best of my knowledge and understanding.
AA7ylt.QQ1) 10(--�v �fjL
Print Owner's or Authorized A enl's Name(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 Hone Improvement Contractor(HIC) Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program can be found at
w,ww.mass. ov'oe❑Information on the Construction Supervisor License can be found at wtvw.mass.¢ovddus
2. When substantial work is planned, provide the information below:
Total floor area(sq. it.)" `�t .(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 ofcooling system Enclosed Open_
1. "folal Project Square Foontge"may be substituted fix"'total Project Cost'
/> CITY OF SALEM, MASSAC HUSETTS
!i BUILDING DEPAR'I'IvIENT
2: 8.
t 120 WASHINGTON STREET,3"D FLOOR
TEL. (978) 745-9595
FAX (978) 740-9846
KINIBERLEY DRISCOLL
MAYOR THOMAS STTIERRE
DIRE CTOR OF PUBLIC PROPERTY/BUILDING CONi UvIISSIONE R
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date
to -3()-t4
Job Location Bac.eMer f
Home Owner Address `f5 Maul boroV42
Present Mailing Address QS 0.)DOUJZ
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
is intended 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. o
HOMEOWNER'S SIGNATURE e U
APPROVAL OF BUILDING INSPECTOR
QTY OF SALEM, MASSAQHUSEM
BUILDING DEPARTMENT
120 WASHNGTON STREET,3' FLooR
" TEL. (978) 745-9595
KIMBERLEY DRISOOLL FAX(978)740-9846
MAYOR THomAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTYAUILDING CONMUSSIONER
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 111.5 Debris,
and the provisions of MGL c40, 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 deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
p�h
Signature of applicant
to -
Date