76 MOFFATT RD - BUILDING INSPECTION a The Commonwealth of Massachusetts
r r Board of Building Regulations and Standards Hz
4 ' a Massachusetts State Building Code. 780 CMR, 7 edition
` Building Pennit Application To Construct. Repair. Renosate Or Demolish a R,i i ed hrotim t
\ One- or Ttru-Fnrnih Dit elling 'nos
�\ This ' ction or Official Use Only —
2VVV� Building Permit imAber,: Date Applied: I 0 O
Siemlture: ""w""� 9r��L • .—Q� 6 ��
Building Conunissi ell Inspector of B&i di g. Dale
SECTIO : SITE INFORMATION
1.1 Property Address: 1.2 Assessors Nlap & Parcel Numbers
7( /Yl n€ FAT —
. Ma NWnher Parcel Number
I.la Is this an accepted surer? yea_ no
P
1.3 Zoning Information: I iA Property Dimensions:
Zoning Dislnct Proposed Use _—.-- Lot Area(sy fo Frontage tit)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
F —
ReyuircJ Provided Required Provided Required PnrvidrJ
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 ❑
Public ❑ Private❑ Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
��2.1 wneri of eeco„rid:� �6 /Jt o�'F' Xo q(J
i�r�._�c��_r-(fie Kasen
Nw ( nnU Address For Service:
�;rignamrc Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New EConstruction101
Existing Building ❑ EEEE
Repairs(si ❑ Alteration(s) ❑ AAlition ❑
Dem Accessory Bldg. ❑ — Other ❑ Specity:
Brie) Descriotiert of Proposed Workz:_ C/Lt c?!/C Sri rG
2rK=
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor;md Materials)
1. Building S I. Building Permit Fee: $ Indicate how tee is deiewuneci
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Costa (Item 6) x multiplier x
i
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List: i
5. Mechanical (Fire
' Suppression) Total All Fees: $
DOb Check No. Check Amount C ash Anioum: _
b. Total Projec[ Cost: $ 0 / 0 Paid inFull 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL) e
License Number Expiration Dale
Name of CSL- Ilulder
List CSI."Fype(xc below) _
\JJrcas fy e Descri pion
1. L+nrestocied (tip to 3i.000('u. Ft.)
R Restricted I.c'_ Family DNelllne
Signature M Masonry Only
RC Residential Kaoline Coscnng
Telephone \\'S Res idemwl \\'indoor .,nd Sidme
SF Residential Solid Fuel Bwnuw \ ihwnt: hut.ill.w� u
D Residential Uemoluwn
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature
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, , 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. - -
i
Signature of Owner -_ _Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
<an
ner r Authorized Agent hereby declare
that the statements and information on the foregoing application are truaccurate, to the best of my knowledge and
behalf.
Drlm VStile
Signature of bwne%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 he found in '30 CMR Regulations I IO.R6 and 1 IO.RS, respectively.
'_ When substantial work is planned, provide the information below
Total flours area(Sq. Ft.) (including garage, finished base men t/attics, decks or porcht
Gross living area 1Sq. Ft.) Habitable room count _
Number of toeplaces Number of bedrooms -_
Number of bathrooms Number of half/baths
'fvpe of heating system Number of decks/ porches
'fvpe of cooling system Enclosed Open
3. 'Total Project Square Footage" may be substituted for "Total Project Cost"
i
CITY OF S.U.EM
PUBLIC PROPERTY
DEPARTMENT
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�� 130ww9utw'Tgi Sn�.T�Su,Fy„ywsupn;g-ns01970
7EJ_978-73S•9S9S• Fnx:973-740-99"
HOMEOWNER LICENSE EXEMPTION
Please Print
Date
Job Location -7la A v Fr A T 2a 4 o
Home Owner Address 76 /h o 26 40
Home Owner Telephone 4 ? S— 74,16 - 4,4 S16 / m
Present Mailing Address 7 6 // a fx lf-27- f2,A o
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Unite 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.
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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR'
cc other side for state code
CITY OF SALEM
. �A�= PUBLIC PROPRERTY
DEPARTMENT
I \s: 'i':t.`a_•I5a,,
Construction Debris Disposal Affidavit
(required l'or all denioIition and renovation work)
In accordance %s ith the sixth edition of the State Building Code, 780 CNIR section 111.5
Dcbris, and the provisions of Ib1GL c 40, S 54;
Building Permit k is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal Facility as defined by MGL c
I 11. S 150A.
The debris will be transported by:
Ch/'iSweole/ Cn yn e
(name of hauler) -
The debris will be disposed of in :
himnr ul Iuc Bity) �
laddress u(IacililVl
�ignawrc it'pcnnit applicant
,rate
� Y
DIVERSIFIED CONTRACTING COMPANY
NEW CONSTRUCTION - RE
ROOFINGCARPENTRY - PAINTING -
3 0 0
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