87 MOFFATT RD - BUILDING INSPECTION � 97
The (bnunonwcalth of N1asstchuSCUS Ia)K
Board of Building RCgulutionS and Standards YII .VI( IP AIJ'll
1 ] $ Mas,ac11usetts State Building Code. 7SI1 CNIR. 7'�' edition I AI:
... 13uddmg I'cnnu Application TO C onsu act. Repair. Renocatr Or 1)cn111,h a RCr„W J lwn„u, �
1. '
(h)e- nr Ttru-f u,nily nnrl[i,,.q f)OS I
l This Sec(ion For Official Use Only
Building Permit i nnhee D ne Applied: — ---
Signature: --_.--
B it is Cunmu„umad Ins) • 'lur of Buildings
SECTION I: SITE INFORM:\"PION
LI Property k iOc}�^ n I 1.2 Assessors NInp & Parcel Numbers ------
I.lu Is This an accepted ,tree[? vex— XL no_ bl:q) Nullifier P:urrl \'wnhrr
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq fU Frontage (h)
1.5 Building Setbacks (ft)
j Front Yard Side Y:uds Rear Turd
! Required Pro%ided Required Provided Required PI,r,i&d!
1.6 Water Supply: (M.QL c. 40. §54) 1_7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? %hmicipul ❑ On site disposal system ❑
Public ❑ Private❑ Cheek if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 wnert f Record: 8� O't"T f` a:t Rod��/� '.
Name lu Address for Service:
C?70 5'�M`
Signulu Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (cheek all that apply)
New Construction ❑ Existing Building f9 Owner-Occupied Repairs(,) Do Alterution(s) Additinn ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify.
Brief Description of Propos d Work': --
=nSSa�1 Twe1V 1s. o ca(,twte.. GJ -1 Owl —
A erse.n too Iert m 3 Dotes R l.!,sno. —
SECTION J: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (I_aborand Materials)
I. 11.111ding $ 47000 .60 I. Building Permit Fee: $ Indicate how fee is Jemrmm�eJ:
❑ Standard City/Town Application Fee
2. Electrical 1S ❑Total Project Cost' (Item 6) x multiplier
1. Plumbing $ '. Other Fees: $ /
4. Mechanical IIIVAC $ I List:
Le
i. iYlechntical (Fire 5
Sup cession) 1'octl All Fees: S
Check No. Check .Amount: <•antt A,nouM:__- _
6. Cotal Project Cost: $ 7d00 .00 ❑ Paid in Full ❑ Outstanding Balance Due:______
SECTION 5: CONSTRUCTION SERVICES 71
5.1 Licensed Construction Supervisor (CSL)
L.irense :\'umber I\pie atiun D:uc
Name of C'SL- [hdder
Lml CSL T\'pc (see below) _
I-v re I Descri ttmn
\dJresx
' C 1'nrrstnctcd nt i to 3�.000('u- FLi
R Restricted I.\:'_ F:umh Drtilluie
S:'naure �'I Ma")IIn Only
RC Rcstdcnnal Routine C'otcnng
Ielcphunc AA'S Res:dcnoal AVinJutt .mJ S:J:n_
SF Rcsidcnral .Solid Fticl Hunan" \ +tli.m.r lu.i.dl.0 ism
D Res:dent"d Denwhuun
5.2 Registered Ilome Improvement Contractor 0110
HIC Company Name or IlIC Registrant Name 12eguuauun ;N'umher
ddress
EXptraao❑ Date
Signature Telephone
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.
Signature of Owner Date
_,t.. SECTION 7bb: OWNER' OR AUTHORIZED AGENT DECLARATION
1, S- t'e•{J�411 L c L,e ry s , 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.
Prim Name //y/10o8
Signature of caner or thorized Agent Date
(Signed under the pains and penalties ofperjury)
NOTES:
I. An Owner whit 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 :recess nt the arbitration
program or guaranty fund under M.G.L. c. 1-1_A. Other important information on the HIC Program and
Construction Supervisor Licensing (CSL) can be found in 730 CMR Regulations I IO.RG and 1 IO.RS. respectively.
'. When ;ubstant al work is planned, provide the information below:
Fowl floors area (Sq. Ft.) (including garage, finished basement/attics. decks orporch)
Gross living area (Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of hathrooms Number of half/haths
Type of heating system Number of decks/ pr)rehcs
I'vpe of cooling system Fnclused Open —
3. "Total Project Square Foofage•• may be substituted for "Fugal Project Cost"
CITY OF SAI.EM
PUBLIC PROPERTY
DEPARTMENT
KIld�C rLw•ry
NAWA 120 wASUNG70N SUM•SALM4%rdASSAd/L'SEl'IS 01970
lklt97@-74S-9S9S• FAX 979-740.9646
HOMEOWNER LICENSE EXEM"ION
Please Print
Date %L!4ZZOOR
Job Location 8 -7 Mod /Q .W*%j mtq
Home Owner Address 5A 120 t
Home Owner Telephone 9?cr9t—SVD-
Present Mailing Address 3 ca rvl C 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 act@ 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 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 "homeowned'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. a�G/
HOMEOWNERS SIGNATUREJA
t'sr
APPROVAL OF BUILDING INSPECTOR P
See other side for state code
CITY OF SALEM
Kz,J, •` PUBLIC PROPRERTY
,� !
DEPARTMENT
\I 1, �I :.1 l.Y ':1. •.).
Nl .,.h I�� `lr\\1 L'�11:\)N S:acET 0 >.v..
'F1 'I'It-,'i5 )")5 • t \:(:
Construction Debris Disposal Affidavit
(required ror all demolition wid renovation work)
In accordance with the sixth edition of the State Building Code, 7S0 CNIR section 111.5
Dcbris, and the provisions ofNIGL c 40, S 54;
Building Permit # _ 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 N1GL c
ILLS 150A.
The debris will be
transported by:
Jq n"T Confr4.W"^ J
tn� cot ilaule �
I he .!.:bri; will be diisposed of in//: