10 MOULTON AVE - BUILDING INSPECTION (6) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
O
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
\\ i One-or Two-Family Dwelling
This Section For Official Use Only
IBuilding Permit Number: Date Appli5d.
"L L Jr -g ��
Building Official(Print Name) Signatu Date
SECTION 1: SITE IN RMATION
1.1 Property Address: 1.2 Assessors Map & Parcel Numbers
/O AP7ro vZ ;70 AC E
1.la Is this an accepted street?yes K no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
IV/SrCoy— s�,f�c. ,
Name(Print) City,State,ZIP
/0y7m�s7cvt-, Ace 1f959360?a1 WISSfR (JAWO+ni.u�+c.e
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied J d I Repairs(s) ❑ Alteration(s) )d Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work': Re,*70 e I W;:f cn
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 500. w 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ 5 00. o o [1 Standard City/Town Application Fee
d. ❑ Total Project Cost'(Item 6)x multiplier x "
3. Plumbing $ 5000, do 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 9000. DO 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 t.onstruction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type -. Description
U Unrestricted(Buildings up to 35,000 cu.R)
R Restricted 1&2 Family Dwelling
City/Town, State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town, State,ZIP 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 lac OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Wtllig,Y, cv. ss£2 /`/ 7—,k J,ia,
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. 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 can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage, finished basement/attics, decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halffbaths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF S.-1LE1ti1, 2UNSSACHUSETTS
• BuMIDLNG DEPART%MNT
13o WASHINGToN STREET, 3iD FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KIMBERLEY DRISCOLL
MAYOR TttoetitAs ST.PtERRE
DIRECTOR OF PUBLIC PROPERTY/BUUMLNG CONMWONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code 780 CMR section 111.5
Debris, and the provisions of MGL 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 MGL c
111, S 150A.
The debris will be transported by:
/o,c 1k4 4,/"/t}
(name of hauler) /
The debris will be disposed of in
(name of facility)
(address of facility)
si attire of permit applicant
date
CITY OF S-UYDfI
PUBLIC PROPERTY
DEPART1dENT
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HOMEOWNER LICENSB EXEINMION
Plow Ries:
Date / J./.L
lob Loead" l
Rome Owner Address e o i"�o 4 C O'
Ham OwnerTelephone I/ I S'9.� G a T 1
Presses Mailing Address /U / 1 o� /Tr,- 4 4.�
no current excuspdoo of"Homeowner"was extended to include owner-occupied
dweuings of two Units or teas and to allow such homeowners to eogsgs m individual for
hire who does not possess a 8eenso provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNMt
Pason(s) who owns a parcel offend as which WAS resides or intends to resider on
which there is, or is intended to bar a one or two faWly dwelling attached or detached
structures accessory to such use and/or Itrm 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 OQkial,on a fort acceptable to the Building
Official, that he/she be responsible for M such wort performed under the Building
Pamit
The undersigned "homeowner'assumes responsibility for compliance with the State
Building Code and other applicable by64aws and reguladona
The undersigned "homeowner^certifies that helshe undentands the City of Salmi
Building Department minimum inspation pros es and requirements and that helshe
.Vill comply with said procedures and requirerp
HOMEOWNERS SIGNATURE (/
.APPROVAL Of WILDING MPECTOR
See other side for state coda