79 MARLBOROUGH RD - BUILDING INSPECTION 4 It
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The Commonwealth of Massachusetts
I1 qp Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For OI)kcial Use Only
Building Permit Number: I 06e Applied:
Building Official(Print Name) Signat"V Date
SECTION 1:SITE INFORMATIO
1.1 Property Address: 1.2 Assessors Map&Kreel Numbers
79 Marlborough Road 09-0002-0
I.la Is this an accepted street?yes no Map Number Parcel Number
.1.3 Zoning Information: 1.4 Property Dimensions:
( t
Zoning District Proposed Use Lot Area(sq fu Frontage(fl)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Wate upply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner[of Record:
Robert R. & Kerr! A. Charland Salem, 14A 01970
Name(Print) City,State,ZIP
79 Marlborough Road (978) 745-2737 kbcharland@comcast.n t
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Buildin Owner-Occupied Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units 1 I Other ❑ Specify:
Brief Description of Proposed Work: Kitchen...replace cabinets; countertops & the
floor.
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 10 000 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 10 0M , ❑Paid in Full ❑Outstanding Balance Due:
75r� 0
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M 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 MC 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...........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 Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering name b w,I e eby atte t under the pains and penalties of perjury that all of the information
c ntained!7s ap tali ccura[e to the best of my knowledge and understanding.
Pri is or Au ri n s ame Electronic Signature) Date
NOTES:
1. 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. o@ v/oca Information on the Construction Supervisor License can be found at www.mass.gov/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.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"
^b CITY OF S.U.&NI, A-us.-kcuUSETTS
BLtIL)LYG DEPARTNONT
120 W-ASHLNGTON STREET, Yo FCOOR
T-EL (978) 745-9595
FAX(978) 740-9846
K!\®ERIBY DRLSCOLL
MAYOR THoma ST.Plzssn
DIRECTOR OF PL auc PROPERTY/KaMLYG 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 t 11.5
Debris, and the provisions of MGL c 40, S 54; .
Building Permit p is issued with the condition that the debris resulting from
this work shall be disposed of in a property licensed waste disposal facility as defined by MGL c
l 11, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit applicant
date
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CITY OF S.UY.Ni
PUBLIC PROPERTY
DEPARTMENT
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HOMEOWNER LICLNSE EXLMPTION
Pfew lMat
Data
Job Loeadois
Home Owner Address S rJ
Home Owner Telephone
Present Mailiag Address
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or lose and to allow such homeowners to engage an individual for
hire who.does not possess a license,provided that the owner acts as supervisor.
DERNMON OF H0112OWNF.R
Person(s) who owns a parcel of land on which he/she resides or intends to reaide. on
whiiab there is, or is intended to be,a one or two family dwelling,attached or detached
strictures 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
'4tomeowner"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 reguladons.
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.
HOMEOWNERS SIGNATLIM ---
APPROVAL OF BUILDING INSPECTOR
See other side for state code
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