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10 MOULTON AVE - BUILDING INSPECTION (5) � � � �7 ���:�_,j_ � i � � 3 , �` '� The Conunomvealth of Mnssachusetts � ���' ` Doard of Duilding Regulations and Standards CI'fY OF j+,.�� Massachusetts State Building Code, 780 CMR SALE�bI Building Permit Application To Construct, Repair, Renovate Or Demolish �l Revised,t/<,r 20l/ One-nr Ttivo-Fnmily Dwel(ing This Section For Otlicial Use Only..: (3uildiny Permit m er. ` Dat .Appf' d: v / uilding fficia (printN• e . � /� . . � �' iynat SECTION L•SITE INF Ri�fATIODI Dat� 1.1 Property Address: " � - � � /O ryjpG� T�� A�� 1.2 Assessors blap g p�rcel Numbers ' i.!a i;Ihi;c;acupted stteet? rs Y� __ no hfap Number Purcel Number '--- 1.3 'Loning Information: L4 Property Dimensions; "Luning District Propused Ua�— . � Lot Area(sy fl) , Prontage(It) I.5 Dui�ding Setbncks(ft) Front Y;ud Side Yards ReyuireJ p�a�i�e� Rear Y;vJ Rtyuired Provided Re uired Q Provided 1.6�Vnter Supply;(M.G.L c.40,§SJ) 1J Flood Zone Information: �'��b���❑ Private❑ Zune: _ Outside Flood Zone? ��8 SeW�ge Disposal System: � Check ifyesO Municipal p pn site disposal system ❑ SECT[ON2: PROPERTYOWNERSHIP� 2.1 O�vner�of Record: ` � � � w/LL/.4,�-, witce� s'9Lfi" . y�q o/ q �N�hme(Pnnq ( � :.��y,siace,zir - - — _!o /�a�tTo.✓ A.- s q/q393Go }d No.midStreM �--=— SeR /.nni• ✓nc. ep/� Talephone Cmail Address SECTION 3: DESCRIPTION OF PROPOSED�VORK'(check nll thnt appiy) New Construction❑ Esisting BuildingJE7 O�yi�er•Occupied � Re airs s ❑ Alteration s ❑ Demolition ry, g � � � � ) Addition � ❑ Accesso Bld , ❑ Number of Units �rief Description of Progosed tiVurk': — Other ❑ Specity: �a FLa,� � o�t„��2 � s� � ,__„`��;��_� �u 6 SECTION.1: ESTLVIATED CONSTRUCT[ON COSTS Item Estimated Costs: L�bOf�p(f�V�,��erials Official Use Only I. 6uilding � o00 �• �uildinr�Permit Fee: � (ndicate how fee is determined: 2 flactrical � a S,00 ❑Sfandard City/Town App�icatiun Fee- 3. Plwnbing ,� � ❑Total Project Cost�(Item 6)x multiplier r o�'� ?. OtherFees: $ /�� 1. �Icehviical (I-IVAC) $ LisC �( �R .i. �\�techonical (Fire )/ 1 Su ressiun) '� 'fotal AII Fees:S 6. Tuhil Project Cust: �S \� g oo Check No. Check hmount: Cash Amount a' r ❑Paid in Full — ❑Outstandin; p�lance Due: - - _� _ _ . _ � � SECTION 5: CONS"CRUC'PION SERVICES , � j,1 Cunstruction Supervisor Liccnse(CSL) _---- � —'�— E.e irulion D�te � License Number P � d Naine of CSL f[older List CSL'fype(sce below)�__— -,�yPe ` <� �� .. :. Descripliort�: . � � N�. :md Street � U �Unastricted OuilJin s u l0 35,OU0 eu.ilJ �t Restr�cted I&2 Famil D�vellin �( Mnson ('Ity/I'own,State,'LlP R� Rootin Cuverin WS Nindow�ndSiJin SH Solid Fuel Buming e\ppliunces ( Insulalion . ------- Email address D Demolitiun Tcle hune _�— �� $,2 Registered tlame[mprovement ConUactor(HI ) — tliC Rcgisuahon Number ��V1fi1110"�p1e HIC Cump:my Nama or HIC Registr�nt N:nne em.������ress Na and Street —� Tele hune . . . � . �� �-. Cit /Town,State ZIP SECT(ON 6:�VORKER$'CONIPENSAT[ON INSURANCE��FFIDAVIT(M.G.[:,c. 152.§ Z�C(�)'... W orkers Compensation Insurance affiduvit must be completed and submitted with this applicatioa Fnilure to provide this afl7davit will result in the denial of the IsSuance of the buildino permit. SignedAtlidavitAttached? Yes ...••.••••� No...........❑ SECTION 7a:OWNER AUTHORiZAT[ON TO BE COMPLETED W HEN: :' O�VNER'S AGENT OR CONTRACTOR APPLIES FOR BUII.DING PERbItT l,as Owner of the subject property,hereby authorize tq act on my behalf,in nll matrers relative to work authorized by this b�ilding permit application. Date Prinl O�mer's Name(Electronic Signawre) SECTIO`17ti:OWNER�OR AUTNORIZED AGENT DECL.ARATION 6y enrering my name below, l herebN attest under the pains:md penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understa��•U�4h �O( ,/r G✓�I�/ �s— 4✓� Sc.. Date Print Owner's or Authorized Agen['s Nnme(L•Icctrunic Signature) . NOTES: � will n�if have access to lhe arbivation �. An Owner�vho obtains a building permit to do his/her own wurk,or an owner who hires an unregistere contrac or � (not registered in[he Home Improvement Cun[recror(HlC) Pro ram), pmgram or guaranty Fund under�I.G.L.c. Id2A.Other impormnt information on the HlC Program can be found at "���� ��;�_ S_�,�[nform:uion on the Construction Supervisor License can be tbund at�v���+' �»'�'+ "��''�Ins � � �, \Vhen substantinl�vurk is plam�eJ,provide the info lma�flo�'n������e, tinished basement/uttics,decks or porch) fotal tloor area(scL ft•� Habitable room count Gross living area(sq• R.)_---- �umber oFbedrooms Vumber of fireplaces ,lumber uf halt/baths ,lumbcr of bnthroums �umber of dccks/porches�— TYPe uf hcating system______—__---- Lnclosed___--_—Open 'Cypc oFcooling systcin . � }. ""Ibtal Prqject Syuare Foolage"m�y be substitureJ tbr"�otal Projac[CosP, 1 /�vr ,.; , � CITY OF S�1L,El�t, i�L�SSACHUSETI'S ?� ' [ � ��u.Ds;cDEr.�x�n�.�r ��,,�~���r''� •, 13O C�/ASHCYGTON STREE7 3T°Ft.00[t `�''� �"'''� "I�L (978) 7�5-9595 K.lttBERL.EY D[27SCOLL F.IX(972) 7-10-9846 ,ti{AY0:3 TT-[OAtAS ST.PIER1t8 . DfRECTaEt OF P�BLIC PROPERTY�BC;ILDL1,'G CO\p(I55[OVEQ .. . _�. » , �.�:.,�,,. , _ _ t,'onstructiun Debris 1Disposai AFfidavit (required For all dcmolition and renovation work) In accorJance with the sixdi edition of the State Building Coda, 730 CMR section i I 1.5 Debris, and die provisions uf i�fGL c 40, 5 �4; Buiiding Permit ik is issued tivith the condition that the debris resulting from this work shall be disposcd of in a properly licensed waste disposal Facility as de6ncd by i�1GL c 1I l, S ISOA. "fhc dcbris will be transportcd by: 9�� S�ti.. /�.,/,��, (namc ut'hauler) 'I'he debris will 6e disposed oFin : ------ (nime of t'acility) -- � • . -------(�ddress of iacility) i . s rnature ofpermit applicant '— � �����, �i�« �i,�i���:,:�;r'.i.:< � �____. _ - _ . __ . __ _ __ _ - -- ---.� � „/`� .�� CITY OF SALEM, MASSACHUSETTS "� � �� �;� BUILDING DEPARTMENT \�\�Q �;���,� .��'� 120 WASHINGTON STREET,3"D FLOOR ��� 'I$L. (978) 745-9595 FAx(978) 740-9846 KIMBERLEY DRISCOLL MAYOR TFIONrns Sr.PiE� DIRECTOR OF PUBLIC PftOPERTY/BUILDING COMMISSIONER HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: Date 9 �ac.-r,.�z- �/j Job Location / O /hv.-/1v� .4� � �'�� �v. /�'1,,�c O/ `� �—c� Home Owner Address S �/�'r � Present Mailing Address S�/✓��— 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 alI such work performed under the euilding 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 euilding Department minimum inspection procedures and requirements and that he/she will comply with such procedures and requirements. 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