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33 MOFFATT RD - BUILDING INSPECTION C �1 The Conunomvealth of Massachusetts pV��Fg � l I Boar)of Building Regulations and Standards 1HSPECTIUNA SE`C`ITY QF I L SALEM Massachusetts State Building Code, 730 CNIR / vi.91.2142011 Building Permit Application To Construct, Repair, Renovate Or mwai is One-or Tivo-Family Divelling This Section For Official Use Only Building Permit Number: _ Date Applied: �i lkiilding Ol'ticiul(Print Name). Signature- Date SECTION L•SITE INFORMATION I.I Property Address: 1.2 Assessors Map&Parcel Numbers Map Number Parcel Number L I a Is this an accepted street?yes no P 1.3 'Zoning Information: 1.4 Property Dimensions: Lot Area(s R Frontage(It) Zoning District Proposed Use q ) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Requi r:ed::= 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? Municipal❑ On site disposal system Cl Public❑ Private❑ Check if yesCl SECTIONZ: PROPERTY OWNERSHIP)' 2.1 Owner)of R cord: S �1- :mot Kr 3. Sl.�moi✓� )me(Print) City,State,ZIP 3 3 wiorr--A%T A- ) _ ej7i-7y1-ztai No.mid Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply) New Construction❑ Existing Buildin Ow net (kit I pied ❑ Repairs(s) t3' A i ition(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ NumberofUnits_ Other Cl Specify: Ftitw'f Pd�•f Brief'Description of Proposed\York': t¢ -fir r r h) 6 'Pr�� y � d�2r't{ _ i SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item Labor and Materials) I I. Building S � ©6 a I. Building Permit Fee:S Indicate haw fee is determined: [3 Standard City/Town Application Fee 2. Electrical S ❑Total Project Costa(item 6)x multiplier x 3. Plumbing S 2. Other Fees: S I.Mechanical (HVAC) S List: 5, iMechanical (Fire S 'total All Fees:S . Suppression) Check No._Check Amount: Cash Amount:_ 6. Total Project Cost: S '1, 0 o ❑Paid in Full ❑Outstanding Balance Due: 5 ca)3 o q-0 i--1• o. 23a1 ^'r'JJ3Yf SECTION 5: CONSTRUCTION SERVICES 5.1 Cunstruction Supervisor Licciiitf(CSL) 8 S V A t , License Number Expiration Date Nnnie of CSL Holder ,. ... "r1 List CSL'Cype(see below) Type Description No. and Street U Unrestricted(Buildings tip to 35,I100 Co. ft.) It Restricted 1&2 FamilyUwelling Citylfown,Sucre,ZIP Ni Masonry RC Rooting Covering WS Window and Siding SF Solid Fuel Burning Appliances f 1 Insulation fele hone Email address D Uemolitiun 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date IIIC Company Name or HIC Registrant Name - No. ,aid Street Email address City/Town,State ZIP Telephone SECTION 6:WORKERS'CONIPENSATION INSURANCE AFFIDAVIT(NLG.L.c. 152.4 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...........❑ SECTION 7a:OWNER AUTHORIZATION.TO HE COMPLETED WHEN: OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,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. I Print Owner's Narne(Electronic Signature) Date / SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION t/ By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information y�\ contained in this application is true and accurate to the best of my knowledge and understanding. KEfr0 �) f/ M0/e -`I— y ( �; t� Print Owner's or Authorized Agent's Name(Electronic Signature) Date 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[Ionic Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under b1.G.L.c. 142A.Other important information on the FIIC Program can be found at www.mass. goL� K 20 Information on the Construction Supervisor License can be found at wiow.mass. c��:'ILs T. When substantial work is planned,provide the information below: total floor area(sq. It.) (including garage, finished basemendattics,decks or porch) Gross living area(sq. It.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/parches Type of cooling system_ Enclosed Open_ 1. Total Proicci Square Footage"may be;ubstitutcd tier"Total Project Cost" r QTY OF SALEM, MASSACHUSETTS BUILDING DEPARTNIENT 120 WASIHINGTON STREET,3m FLOOR TEL. (978) 745-9595 FAX(978) 740-9846 KIMBERLEY DRISCOLL MAYOR THONIAS STTIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING COMIVIISSIONER HOMEOWNER LICENSE EXEMPTION PLEASE PRINT:RI Date / (I 5 // N Job Location 3 3 Home Owner Address S na Y Present Mailing Address S Pr 04 1— 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 that does not possess a license, provided that the owner acts as supervisor. DEFINITION 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 understand the City of Salem Building Department minimum inspection procedures and requirements and that he/she will comply with such procedures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING INSPECTOR 9 . 4 ��SrF CITY OF S:U EM, A-USACHUSETTS 13LIMLNG DEPART. LENT •;,\�"l Syr` 130 WASHNGTON STREET, 310 FLOOR TtL (978) 745-9595 KIN iHERI Y DRISCOLL F.Lx(978) 74t-9845 &LILY011 THOAAS ST.PiE.W Di.0 rOR OF PUBLIC PFtOPERTY/BUILDLN(;COSOUSSIONER Construction Debris Disposal Aftldavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 CMR section l l 1.5 Debris, and die provisions of NIGL c 40, S 54; Building Permit hl 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 L%YIGL c l It, S 150A. The debris will be transported by: (I PA (lama ut'hauler) The debris will be disposed of in : 6V 0,'L F%4—S (narne of facility) — --_(address of tacility) signature of permit applicant ,Luc --