101 MARLBOROUGH RD - BUILDING INSPECTION (4) The Commonwealth of Massachusetts
VE,
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CNIR SALEM
� Revised.LJnr 7011 i
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date"Applied: /
a /'3
Building Official(Print Name). c�r-,ra �ej: Signature/ Date
SECTION 1:SITE INFORMATION"
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
Mt 16) 0rn
I.la Is this an accepted street?yes V no Nlap Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(II)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check ifyes❑
SECTION2: PROPERTY OWNERSHIP`
2.1 Owner'of Record: 1
�arv. CL,ee,vcr & H c�wr3 Sw �� Sc`e w. ,M� Q147d
me(Print) ,r� City,State,ZIP
B
lot MurOooy- UR 11 RJ rrO y,-Z-IO-77OOX / �G�eeV�r2'y`O Mnil. Ga
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) JR I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work-:.JFSr-4Lb PL .v,ov=tcz
\ SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item (Labor
Costs: Official Use Only
Labor and Materials)
I. Building :� I. Building Permit Fee:S Indicate how fee is determined:
�. Electrical ,S ❑Standard City/Town Application Fee"
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S
Su ression) Total All Fees:S
Cheek No._Check Amount: Cash Amount:
6. 'total Project Cu t: 41000 -(O,O 0 Paid in Full 0 Outstanding Balance Due:
t
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name orCSL[folder
List CSL"type(see below)
No.and Street Type' - - Description .
U Unrestricted Iluildin>s tip to 35,000 cu. It.)
R Restricted 1&2 Tamil Dwelling
Citylfown,State,ZIP tM Misonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel fuming Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
Ii1C Company Name or HIC Registrant Name - -
No.and Street Email address
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'CONIPENSATION 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 Is§uance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No...........❑
SECTION7a:OWNER AUTHORIZATIONTO 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 Name(Electronic 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[lhis�n is true and accurate to the best of my knowledge and understanding.
/ LO ZU33
Print Owner's or Autlwrized Agent's Name(Electronic Signature) DatT e
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires at 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
�rww.nmss.eov`oca Information on the Construction Supervisor License can be found at Www.mass.'�ov:'dns
2. When substantial work is planned,provide the information below:
"total floor area(sq. ft.) (including garage, finished basementlattics,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. "fotat Project Square Footage"may be substituted for"Total Project Cost"
CITY OF S.1 -E,til
PUBLIC PROPERTY
DEPART,tiLENT
Q I aWA at OAMLL a,
sores
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ML f'a 11L71•t •Y.uL 9?at+e•1W
HOMEOWNER L.ICE,VS9 EXE.Mnloll
Pfew Print
Due 10r`+/1, ,
lob Lacado. -Foor-
A ... .aoM cba�1�c pow
01+76iom1Owner 6
Home0womTelepboae9�3-ztct-9ooB �K�. ro, 9�8 ��ro-vaa8 Cra
Preset Mailing Addrlr
Tie curses exempdoo of"8omeow we wee eatendetl to inchads owner a"Iod
dwelllnp ottwo Unite or teat ad to aliowr aucb homeowners to CUPP ao individual for
hire wile does oot paaaess a liceau4 provided that the owner acts as eapeeviacr.
DEFINITION 01 HOAa0WMM
Peasoaa(s) *he owns a peroal otWW oil which hdahe resides a Intrrada to rt ldeti as
which chart tti or Is intended to be; a ace or tyro Of dwellLtg, attached or detached
atn>enuea accessory to such use aysd/or (arm aWxnuea A permit who comeucts more
thaw one home ilia s two year period shad not be co*ddered a homeowner. Such
m"hoeowner'shall submit to the Building OQlcial, on a font acceptable to the Building
Permit hdahe he responsible for all aucb want performed under the Building
The undenitrted "homeowner""tomes responsibility for complianes with the State
Suiiding Code and other applicable by-lawn and retulaufons
The undenigted "homeowner'certifies that hdshe understands the City of Salem
9uildin1 Department minimtua irupection procedures and requimmrtents .and that hdshe
.rill comply with slid procedures utd requirements
HO tifEOWNERB SIGNA iT,,�
kPPROVAI. OF 9UILDING !,`fSPECT0
ice ahcr lids Far scat*C04
CITx OF Si LENm. NL-�SSACHUSETTS
f BUILDING D EPA fLTMMNT
130 WASHNGTON STREET, 3" FLOOR
TEL (978) 745-9595
FAA.(978) 740-9844
KI\iBERL.EY DRISCOLL
NLAYOR THo.%w ST.PtERRa
DIRECTOR OF PUBLIC PROPERTY/B1211DL\G COSLMISSIONER
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 c 40, S 54;
Building Permit# 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
111, S 150A.
The debris will be transported by:
y Nor4P 5l' ,-e-c-y1;.:
(name of hauler
The debris will be disposed of in
(name of of facility)
(address of facility)
signature of permit applicant —
date
aa �»a:a,x