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3 OAK ST - BUILDING INSPECTION (2) F45- /L/ - G -71 ' (p58 — 1 c,t< 4sm Vz5 °o 'rile Commonwealth of Massachusetts CITY OF Board of Building Regulations and Standards SALEM I' Massachusetts State Building Code, 7S0 CNIR Revised.t/ur 2011 7 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Tivo-Family Dwelling This Section For Official Use Onl Building Permit Number: Date A [led: Building Official(Print Name) Signature- Date I SECTION 1:SITE INFOR;�IATION' \v/ ruperty Ad ress: y LI Assessors Map 3t Parcel Numbers f/.)rr r �czk L I a Is this an accepted street?yes, no Nlap Number Parcel Number 1.3 'Zoning Information: 1.4 Property Dimensions: I Zoning District Proposed Use Lot Area(sq 11) Frontage(11) 1.5 Building Setbacks(ft) Front Yard Side Yams Rear Yard ' Required Provided Required Provided Required Provided 1.6Water Supply:(M.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑ I'ubiic❑ Private❑ Check if es❑ F SECTIONI: PROPERTY OWNERSHIPI, 2.1 1 1 Ce Fir aPRecy -g(?e/$�1 s ��1 p 6�/ () (p nt) City,State,ZIP /V�/c�iel� �o�insah Y-e "9 Bad /�y��5"©YerixoN,N No. cold Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction CI Existing Building❑ OwnerOccupied ❑ Repairs(s) ❑ Altention(s) ❑ Addition Cl Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify: U ' -Description of Proposed Work: we- l—ctp I aG C e, 2 T- ,S}1'YKfi e6 n SECTION 4: ESTIMATED CONSTRUCTION COSTS [Celli Estimated Costs: Official Use Only Labor and Materials) I. Building S i, Building Permit Fee:S Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S 0 Total Project Cost'(Item 6)x multiplier x J. Plumbing S 2. Other Fees: S / I. Mechanical (IIVAC) S List: �( 5. :\Icchanicul (Fire Total All Fees:S _ X S rcssiun) — Check No. Ch ;\eckmouuk Cash Amount: 6.u'fatal Project Cost: S aV0, � ❑Paid in Full ❑Outstanding Balance Due: r t SECTION 5: CONSTRUCTION SERVICES 5.1 C'oustruction Supervisor License(CSL) License Number E.xpimtion Date Name of CSL Holder List CSL Type(see below) "type Description No. and Suet U Unresuicled(Buildings LID to 35,0011 cu. It.) R Restricted l&2 Family Dwelling C'ityfrown,Slate,ZIP b1 Masonry RC Roolinat Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address U Demoon j 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date HIC Company Name or 111C Registrant Nwne No. and Street Email address € City/Town,State ZIP Tele hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(NI.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 Wtiance of the building permit. Signed Affidavit Attached? Yes ..........❑ No...........❑ SECTION 72.OWNER AUTt(QRIZATION..TO BE CONIPLETED W HEN: OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize t9 act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Mane(Electronic Signature) Dote SECTION 7b: OWNER'ORAUTHORIZED AGENT DECLARATION By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information I contained in this application is true and accurate to the best of my knowledge and understanding. /yl,che)e- � c�ohv�sorl Prim Owner's or Authorized Agent's Name(Electronic Signature) Data NOTES: I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (nut registered in the Home Improvement Contractor(HIC)Program),will no have access to the arbitration program or guaranty fund under NI.G.L.c. 142A.Other important information on the HIC Program can be found at www.nmSS. �oL L Information on the Construction Supervisor License can be lbund at%ww.mas,-o ov:hlm 2. When substantial owork is plumed,provide the information below: Total floor area(sq. It.) (including garage, finished bascment/attics,decks or porch) Bross living area(sq. 11.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Fype of coolie;system Enclosed Open_ 1 "Fatal Project Square Fooatge"may be substituted for'Tot:d Project Cost" CITY OF SALEM, MASSACHUSETTS BUILDING DEPARTMENT 120 WASHINGTON STREET,3m FLOOR TEL. (978) 745-9595 FAX(978) 740-9846 KINMERLEY DRISCOLL MAYOR THOMAS STTIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: rG Date 0--A � 0 Z , 7 II � c y Job Location 3 ��K ` z S 0 V+f(Pi GQS Home Owner Address Present Mailing Address :5a m e, Z< 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/shebe.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 understand the City of Salem Building Department minimum inspection procedures and requirements and that he/she will comply with such procedures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING INSPECTOR CITY OF S�V—ENf) tiL-1SSACHUSETTS t y st B1:ILDL%1G DEPARTU&NT 130 WASHNGTON STREET, Y°FLOOR . �''s TEL (978) 745-9595 FAA(978) 740-9845 K!\tHERL.EY D2ISCOI.L �bL1Yo;L IT-totiLis Sr.Pt;rRns DIRECTOR OF PI;BLlC PROPERTY/BCILOLNG CON p(ISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 CMR section l 11.5 Debris, and the provisions of NIGL c 40, S 54; Building Permit kk 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 MUc 111, S 150A. The debris will be transported by: (name of auler) The debris will be disposed of in (name of facility) ot'rtcility) signature ot.permit applicant I:uc --