1 MCKINLEY RD - BUILDING INSPECTION (2) 1
I The Commonwealth of Massachuscits
Board of Building Regulations and Standards CITY
Massachusetts State Building Code. 780 CMR "edition OF SALEM
. 7' RreisrJJmnrmr
/►� Building Permit Application To Construct, Repair, Renovate Or Demolish a
(/ J One-of Two-Fa 7P Dwelling
This Sectige(Nr Official Use Only
Building Permit Num Date Applied:
Signature:
Building Cunnmissionerl In for of B r)am
SE 1 1:SITE INFORMATION
1.1/ Ad/,vdress,`G C� Fj O',V ,i7 1.2 Assessors Map A Parcel Numbers
I.I a Is this an accepted street?y`es L!no Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use La Area(sq Il) Frontage(B)
I.! Building Setbacks(R)
Font 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❑ Zorn. _ Outside Flood Zone? Municipal❑ On site disposal system O
Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
kCN -
of Record• T /IP t) Address for Service:
um Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
onstruction n❑ Existing Building❑ Owner-Occupied O Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.O I Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
02 cGk
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S1. Building Permit Fee:S Indicate how fee is determined:
2. Electrical Is ❑Standard City/Town Application Fee
O Total Project Cost (Item 6)x multiplier x
3. Plumbing s 2. Other Fen: S
4. Mechanical (IIVAC) f List:
5. Mechanical (Fire s
Suppression) Total All Fees: f
O Check No. Check Amount: Cash Amount:
6. Total Project Cosh f O Paid in Full ❑Outstanding Balance Due:
aS- ,�, 0A60
SECTIONS: CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor(CSL)
License Number Expintiun I}ale
Name ut'CSI.-I lulder I.ist CSL Type(see below)
f lkwripeion
Address U Iimestricted i.. w 75,000 Cu.Ft.
R Restricted IA2 Famil Uwellin
Signature M M IMI
RC Residential Reufin Coverin.
felepM>ne WS Residential Window and Sidin
SF Residential Solid Fuel Bumin Appliance Installalion
D Residential Demolition
3.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or IIIC Registrant Name Registration Number
Addmu Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. ISL f 23C(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 ..........0 No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to
Si tree permit application.
ZY=77—
Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
l ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are we and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Siwwd under the vains and penalties of '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 Home Improvement Contractor(HIC)Program), will Rg 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 I IO.R3,respectively.
When substantial work is planned,provide the information below:
Total floors area IS
q. Ft.) (including garage,finished basement/anics,decks or porch)
Gross living area(Sq. Ft.) flabiiable 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
J. "Total Project Square Footage"maybe substituted for"Total Project Cost"
CITY OF SALEM
PUBLIC PROPERTY
DEPARTTAAENT
K110L!w paw.v.
NI`"Oa I30wASUNG7OM"Mi r•SMAK MASAGILSIr s 019'0
TT:i.9'67354S" • FAx 93.740.964
HOMEOWNER LICENSE EXEMPTION
Plew Print
Dace qa3
Job Location
Home Owner Address lyrG/Ti Kl�� /2GiV
Home Owner Telephone
Present Mailing Address
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or Ids and to allow such homeowners to engage an individual for
hire who does not posses a license,provided that the owner act@ as supervisor.
DEFINMON 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said proceduresan uirements.
HOMEOWNERS SIGNATURE
,APPROVAL OF BUILDNG INSPECTOR 4�zmzz
See other side for state code