81 MOFFATT RD - BUILDING INSPECTION (2) t
I'lie C'onunonwealdt of Massachusclts
--Board 01'I1(lilding Regulations and Standards ( i'I'1' OF
s?L „ "iassachluctts Slate Building Code, 73U('M1IR SALEXI
Building Permit Application To Construct. Repair. Renovate Or Demolish a Rel A"d I hir'n//
One-or Two-fitntils' Du ellinp
This Section For Official Lse only
Building Permit Number: _— Da Applied:
Budding Ofheial tPrmt Munc) 30
Signature I>alc
SECTION 1:SITE INFORMATION
0
t �oper Address: SECTION
Assessors Map di P reel Numbers
�r
I.la Is this an acce led street? es no Map Nunlher Purcel Number
1.3 Zoning Information: 1.4 Property Dimenslons:
Loring D� islr— ici Propn tjUva Llll Area(tl 11)
4 1.5 Building Setbacks(it) I•ronlage III)
From Yard Silo Yams
Reyuircd I'rvviJed Requited Side
Neyuimd Near YardProvided
1.6 Water Supply:(M.G.1.c.40.§54) 1.7 Flood Zone Information: 1.8 SewaQe Disposal System:
Public❑ private❑ Zone: _ Ouuide Flood Zunt?
CAtck il' a0 MWICIpaI❑ Om silt disposal s)slem ❑
wnertofRhcord:
SECTION I: PROPERTY OWNERSHIP'
p
r.w 0-Irri S
Ll)/,/ ,,Ae_W` O n1 l -7 C)
N.an (Print) Ciq.Scott.ZIP
Nu.,utJ Stntl Yoh �G Cow
telephone F.muil Address
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alterat(on(s) ❑ Addition ❑
Denwlition ❑ Accessory Bldg• ❑ Number of Unib
Brief DescriptionofProposed Work=: -- Other ❑ Specify:
f31[ Ito U�ck;
c�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
licm Estintaled Costs:
(Laborand.klaterials) OMC141 Use Only
I. Building S I. Building Permil Fee: S Indicate how fee is determined:
2. F[wrical S ❑Standard City!Tuwn Application Fee
?. Plumbing S ❑Total Project Cost't ltens 6)x multiplier _ x
2. Other Fees: S
J. \lee h.mic.il ill% No S List:
I \lechanie.tl .Fire ------
s - - - - .._
`u +ressuml Total All Fees: S
/ 6 Total Project Cusl: S L)/pvQ l"heck \o. _ —( heck amount: . l',ish \nuuml
❑ PaiJ in Full 0 Outstanding Bal;osce Due
St,A"I'lON 5: CONS 1-11 ION SVRVI( FS
Icell1c Nilinkir
I Famer I Ist 01. (,.N PC Oec hel,m)
PC DcsRipliun
rect I[ 1 inresuictcd I lltlildill`'t10 12 14 moo au
M
010',11111,S1.11c Till
KC Rmifin Cowrin
A S window and Sidin
SF solid Fuel litiming \Pplijnces�
Insulation
I'ek 111olic Inailaddre.s.4
D Demolition
Improvement Contractor(HIC)
I;,\JliraIivn
I 11C Itcgistraliun Number
Dale
Name or I 11L lwslmra-Nance
i:muil address
No.and Struet
rckLhone
C ity/T w ,state ZIP
INSURANCE AFFIDAVIT(M.G.L C. 152-1 2SC(6))
SECTION 6:WORKERS'COMPEN3A I IUM I with this application. Failure to provide
Workers Compensation Insurance affidavit must be completed and submitted
this affidavit will result in the denial of the issuance of the building permit.
Yes..........C No...........C3
Signed Affidavit Attached? ..........
SECTIONSECTION:Fa:- 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.
Data
Print prini,O,,ncr-s N.ic(Electronic Signalurc)
SECTION 71):uITII&I11% OR AUTHORIZED AGENT DECLARATION
By entering my name btlow. I hereby attest under the pains and penalties of perjury that all of the information
contained in this ap lication is true and accurate 10 the best of my knowledge and understanding.
512-'711-Z
A - ,
(9�Z / Dale
or
'red 6 u,.,,I r a u r
I.
tered cuntriour
building permit to do hilther own work.or an owner who hires an unregistered An Owner\Ou obtains a have
access
b ra"c"
I[lot registered in the Hume Improvement Contractor(1-110 Program),will M)J have access to the a,
d
progrill,or guaranty fund under\1 G.L.c. 141.4. Other iniportant information on the HIC Program
ograin can be found at
can be found at V\ 'It"
0 Information on the Construction Snpervisorl-icenseca
basement
ent It Iles. .k
planned, pro%ide the inturnintiun below: finished
decks or porchi
fatal\\Ihen substantial cork is I including gArIge.
flour area oq. .0 it 11 1
truss I i%ing area I sq. I) Ilabitablo room count
I \L1111ber Of I-replaces
NjImilcr A hall hall"
I)Ilk:lit'he'16119 i\'IcIn 01len
slet"
111r..kital Ilrojeo 01st"
1.
Joial Project ~Hoare Fool.lec"Ina) kJhN11w1Qd
CITY OF S.U.E.Nf
PUBLIC PROPERTY
DEPART LENT
Vwroe i�e v►.ww.,aM srt.sar•su.a�VWs�owssm Ot•-e
ML f'f 74f 9N! . Y.vl 93.7+69 W
HOMEOWNER LICENSE EXE.1d MON
Plow "I
Date s�a9 tL
lob London 8( r•1 ��tF
Home Owner Addtese 81 Mag e fl-
Home Ow aW Telepboee 7-78 7yy &9Z 7
Present Madbg Address bl M&47rAg 2 Saier-, MA 0/4?0
The currents exemption of"Homeowners"was extended to inchWe owmer-oeeupied
dwellings of two Units Of fens sad to Allow such homeowners to eegage an individual for
hire who does not possess a licenseb provided that the owner acts as supervisor.
DEFINITION Of HOMEOWNER
Person(s) who owns a parcel offend on which hdsM resides or intends to reslde6 on
which then isi or is intended to be,a ace or two &m ft dwelling attached or detached
JWxttsres aeceuory to such use and/or farm structures A person who constructs more
than one home in a two year period shall not be conaidered a homeowner. Such
"homeownd'shall submit to the Building OQlcia% on a form acceptable to the Building
Ot71ciaL that hdshe be responsible for all such wort performed under the Building
Permit.
The undersigned"homeownce assumes responsibility for compliance with the State
Building Code and other applicable by-laws and mgWadons.
The undersigned "homeowner"certiifes that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
.vill comply with said procedures and requirements ,
HOMEOWNERS SIGNATURE �r� J
APPROVAL OF BUILDING MPECTOR
See other side for stale coda
CITY OF S.V-&Nt, ► US.ICHUSETTS
tiLUC-IG OEPmmLLVT
1'O %V-U-4NGTON STXW, YO ftOOlt
rRL t.973) 141-9501
FAX(978) 7449su
!U1�FJtLJBY DIILSCOLL I
MAYOI! MO.►W ST.PM"S
OIRSL70 tt OP PL auc PROPHRTY/BC QDLVG C01L♦IIS3ION E1{
Construction Debris DISPOS21 AdIdavit
(required for all demolition and renovation work)
►n sceardance with theaixth edition of the State Building Cade, 190 CMR section 111.5
Oebris, and the provisions of;VIOL a 40, 3 34;
Building Permit a is issued with the condition that the debris resulting from
Ihis work shall be disposed df in a properly licensed waste disposal facility as defined by,VIOL c
I I I. S I JOA.
The debriswill be transported by:
(name of hauler)
The debris wi 11 be disposed of in :
y
r J_
(name o-1111y)
(Jddrel! of rJtIIJiy)
u�nJnue ufpermitJpphcana
��ZL� �z _
.Jfe