85 MARLBOROUGH RD - BUILDING INSPECTION (2) /• , l /e- /C/GG d 4 1,,�r
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
t,� g Code, 730 CMR, 7'"edition OF SALEM
Massachusetts State Building Revised January
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1• =008
One-or Two-Family Dwelling
Thi ction For Official Use On '
Building Permit Num er: F I I I Date Applie
Signature:
Building Commissioner/Inspector fflVkV Dale
SE TON 1:SITE INFORMATION
1.11.1 Pr�Address: / 1.2 Assessors Map& Parcel Numbers
I.1a Is this an accepted street?yes no q/ Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
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 twnertof ecQrd: �7 c
Nam rin ) a. Addre or Service:
-® -7 y0 -3/yA,
Signa telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Posed Work'-: �I A e ",r-y l*— AD+1O_�e0
LAJ r 1h�G�r—ttr (' d— —rDc. rn-�. U
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building S I. Building Permit Fee:$-CZ��Idicate how fee is determined:
❑Standard City/Town Application Fee ell r�1
2. Electrical 3 ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: S
4. Mechanical (FIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
Check No. Check Amount: Cash Amount:
6.Total Project Cost: �5 �'�,(� 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL- Ilulder List CSI.1'ypc(see below)
rype Description
Address
IJ Unrestricted(Lip to 35.000 Cu.Ft.
12 Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC Residential Rooting Covering
Telephone \VS Residential Window and Siding
SF Residential Solid Fuel Burning A fiance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrar Name Registration Number
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, 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.
Signature of Owner Date
S CTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and informatiod on the foreg ing application are true and accurate, to the best of my knowledge and
behalf.
Print me
Signature of Ownefor Authorized gent Date
(Signed under the pains and penalties of er'u
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 Flame Improvement Contractor(HIC)Program),will nor have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.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.UY—NI
PUBLIC PROPERTY
DEPART'A%tENT
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t1L.f'Lt+L7Sf!�F.�s f'L7�6fW
HOMEOWNER LIMNS6 EXE.MMON
Pletw plat
Dan
Job Loradan S ru
Hams Owner Address 6
Ho=Owmr?elephooe - -�/ .ice v
Presort Mailing Adams.. i U-1�1* A,, g �
ns currsat exemption ot"Homeowna a was extended to include owner-occupied
dwellings of two Units of leas and to allow such homeowners to=gap an individual for
hire who.does oat possess a Iiccm4 provided that the owner acts as supervisor.
DBFINMON OF HOhMOWNEA
Person(s)who awns a peed offend on w"bdsbe resides or Intends to resider on
which then is, or is intended to bs,a one or two dunily dwelling,ansched or detached
structures accessory to such use and/or Farm swctures. A person who constructs more
than one home in a two yew period shall not be considered a homeowner. Such
"tsorneowner'shall submit to the Building Official,on a form acceptable to the Building
Oillcial, that he/she be responsible for all such work performed under the Building
Permit
The undersigned"homeowner'assume,responsibility for compliance with the State
Building Code and other applicable bylaws and regulations
The undersigned "homeowner'certifies that he/she understands the City of Salem
Building Oepartmcni minimum inspection procedures and requirements and that heisite
will comply with said procedures and requirements
HOMEOWNERS SIGYATG —
.APPROVAL OF BUILDI.VG 04SPECTOR
See other side for state coda
CITY OF S.XI.E.NI, NLxSS.�CHUSETrS
• BUILDNG DUARTMENT
' 120 W.UHNGTON STREET, Yo FLOOR
TM (978) 745-9595
PAX(978) 740-9846
K1JtHERLEY DRLSCOu
MAYOR THows ST.PrF�ttte
DIRECTOR OF PCBLIC PROPERTY/HCIIDLYG CO%wisSIONER
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 a 40, S 54;
Building Permit Al 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:
—`�)v,M jg s-fie. (—
(name of ha ler)
The debris will be disposed of in
(name of facility)
(address of facility)
Signature of permit applic t
dale
Icbnatlf.4a