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14 1-2 MEADOW ST - BUILDING INSPECTION 5 I The Commonwealth of Massachusetts Board of Building Regulations and Standards FOR 'h Massachusetts State Building Code. 780 CMR. 7 edition Ml1Nil'F�LI'il'Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Atimat r One- or Tiro-Family Dwelling 1, 2008 This Section For Official Use Only Building Permit Num Date Applied: Signature: BuilditilIt Commissioned Inspector of Buildings Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Mop & Parcel Numbers 1.la Is this an accepted street?yes_ no_ Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq It) Frontage(fo 1.5 Building Setbacks(R) 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: f ! PROPE�R7TT Y�OWNERSHIP' 2. / erS'O Record: A7 e R L D R/ / / Name(Print) Address for Service: �/ `�i r7 - ignatwe Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply) New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ¢I Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify: Brief Description of Proposed Work2: SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined: Standard City/Town Applica ion Fee 2. Electrical $ 6 U s ❑ oral Project Cost (Item 6) x multiplier x 3. Plumbing $ 2. Other Fees: S 4. Mechanical (HVAC) $ List: / 5. Mechanical (Fire $ Total All Fees: $ Su ression) / Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ ! l YOD.as ❑ Paid m Full ❑ Outstanding Balance Due: SECTIONS: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) License Number Expiration Date Name of CSL- Holder List CSL Type(see plow) Type I Description 4ddress U Unrestricted(up to 35.000 Cu. Ft.) R Restricted 1&2 Family Dwellin Signature M Masonry Only RC Residential Roulling Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Bumm A pliance losiallauon D Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Company Name or HIC Regislrunl Name Registration Number Address Expiration Date Signature Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 5 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure nt provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes .......... ❑ No........... b 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. Signature of Owner Date SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION I , as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf. Print Name Signature of Owner or Authorized Agent Date (Signed under the pains and penalties of perjury) 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 not have access to the arbitration program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and Construction Supervisor Licensing (CSL)can be found in 780 CMR Regulations 1 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" 1 CITY OF &U EM . PUBLIC PROPERTY DEPARTMENT KI�OI�ev tuw-,v NAWA 130 WMMNaroN SMLE"•C4MAK NASSAQIL'SEI'IS 01970 lFi 97474S-9S"* FAx:978-740.9846 HOMEOWNER LICENSE EXE.IMMON Please Print Date Job Location /` �f%2 /l? a d4 Sr (I) Home Owner AddressA- Home Owner Telephone Cl,,;' - 7�9- ;KG fo Present Mailing Address l x;`4 sr 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 who,does not possess a license,provided that the owner acts as supervisor. DEFRMION 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 fort 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 procedures and requirements. HOMEOWNERS SIGNATI.'RE-� � �r APPROVAL OF BUILDING INSPECTOR See other side for state code CITY OF SALEM nn� P LBLIC PROPRERTY DEPARTMENT T" .; , I. NJ.`.K Li VV.,9IIXG:JN S:BEET 1 S.,L; M, \f.,:;.,c:;it ,r.I -rn.978.74i-9595 • F.vc:978J4,.-A46 Construction Debris Disposal Affidavit (required for all demolition :uid renovation work) In accordance with the sixth edition of the State Building Code, 'SO CbIR section 111.5 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 properly licensed waste disposal facility as defined by MGL c I 1 I. S 150A. The debris will be transported by: (name of hauler) I'lie Jcbris will be disposed of in : t name of lau;ny) © (— 0 /—D U