12 OAK ST - BUILDING INSPECTION (3) r 1
2L The Commonwealth of Massachusetts
f, Board of Building Regulations and Standards CITY
Massachusetts State Building Cute, 780 C'MR, 7
g Nedition OFSALEM
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Revrrrr/Jmnngs•
Building Permil Application To Construct, Repair. Renovate Or Dem olish a
One-or'pV0--T2lq1gy Dwelling
Th' Section Oftcial Use Only
Building Permit Number: to Applied:
Signature: Th
Building Commissioned Impeetar din Date
ION 1:SITE INFORMATION
rIJ
Props Address. 1.2 Assessors Map A Parcel Numbers
e ted street?yes no Map Number Parcel Number
Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lol Arco(sq 11) Frontage(11)
1.5 Building Setbacks(n)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1.c.40,§Sa) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposals stem ❑
Check if a❑ y
SECTION2: PROPERTY OWNERSHIP'
2. nertofRfeoi��� `7 —ca'e_ tQr�
I Pnnt) •' Address% LC� �C-j C—:�2 7'73 74
Signaure Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(Check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION/: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OMCISI Use Onl
Labor and Materials y
7
I. Building is 1. Building Permit Fee:s Indicate how fire is determined:
❑Standard City/Town Application Fee
-. Electrical s ❑Total Project Cost'(Item 6)x multiplier x
1. Plumbing s 2. Other Fees: S
4. Mechanical (IIVAC) s List:
S. Mechanical (Fire S
Suppression) Total All Fees:S
Check No. _Check Amount: Cash Amount:
6. Total Protect Cost: s ,�' 0 Paid in Full 13 Outstanding Balance Due:
d s
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
l.iccnse Number Expiration Oute
Name of CS I.• I folder List CSL f ype(+te below)
f Oescri ion
:\ddmw U unrestricted too to 35.000 Co.Ft.
R Restricted Id2 Famil Ihvellin
Signature M Masonry Intl
RC Residential Routine Covering
I'dephrme INS Residential Window and Sidi.
SF Residenrid Solid Fuel Buunin A liance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
Inc Company Name or HIC Registrant Name Registration Number
Address Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152. i 2SC(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 ..........a No...........O
SECTION 7n: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.
7S��A �IhA
um of Owner Date
SECTION 7W-OWNERr OR AUTHORIZED AGENT DECLARATION
,as Owner or Authorized Agent hereby declare
the statements and in ormation on the foregoing application arc we and accurate,to the best of my knowledge and
lf.
Nome �' .U
ture of(honer or Authorized Agent Date
under the airo and penalties of 'u
NOTES:
n 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,g have access to the arbitration
rogram or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program andonstruction Supervisor Licensing(CSL)can be found in 790 CMR Regulations I l0.R6 and 110.RS,respectively.hen substantial work is planned.provide the information below:
floors area(Sq.Ft.) (including garage, finished basement/anics,decks or porch)
living arm(Sq.Ft.) Habitable room count
er of fireplaces Number of bedrooms
er of bathrooms Number of half/baths
of heating system Number of decks/porches
of cooling system Enclosed Open
J. "Total Project Square Footage"may be substituted for"Total Project Cost"
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CITY OF SALEM
PUBLIC PROPERTY
DEPARTNMENT
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HOMEOWNER LICENSE EXEMPTION
Please "I
Date b
Job Location —2— 0L
Horne Owner Address
Home Owner Telephone
Premes Maidag wmroa.
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
hire who,does not possess a licenm provided that the owner acts as supervisor.
DEFINMON 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
structure* 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 all such work performed under the Building
Permit.
The undersigned "homeowner'assume*responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner"certifies that he/she understands the City of Salem
Building Department minimum inspection procedure* and requirements and that he/she
will comply with said procedure* requirements.
HOMEOWNERS SIGNATURE "ct't—,
APPROVAL OF BUILDING CISPECTOR
See other side for state code
I
CITY OF SALEM
, r PUBLIC PROPRERTY
DEPARTMENT
120 WA.iI]IN(,1 ON S'I It H'T • SA I'M,
TeL_1)78-74;-9595 ♦ Pas:978 74G9846
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 it _-_ 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:
.. :........
(name of hauler)
The debris will be disposed of in
(name of facility
scz&.n Sr of-E
(ad ressorfhcility)
signature or permit applicant
Z I(.
date —
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