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1 OAKLAND ST - BUILDING INSPECTION The Commonwealth of viassaclCEIVEO � `� rr10NAL SERVIC CITY M Board of Building Regulations and land ifS SALEM qYl / Massachusetts State Building Code, 78))Onn��CSSMR y��l If Revised.Nur 2011 Building Permit Application To Construct, Repair, R211b4dlLP&Zgmbish 2 3 One-or Tivo-Family Dwelling C — This Section For Official Use Only yyy�............��� Building Permit Number: Date.Appliedr Building 011icial(Print Nane). Signature• - —D—ale SECTION I:SITE INFOR,NIATION. _ 1.1 Property Address: c� 1.2 Assessors Alap&Parcel Numbers I aA,4L O-0 ST- >s,t e t d`1A I.I a Is this an ecce ted street?yes no Map Number Parcel Number 1.3 'Zoning Information- 1.4 Properly Dimensions: Zoning District Propose)Use Lo[Area(sq It) Frontage(It) 1.5 Building Setbacks(D) Front Yard FFlood de Yards Rear Yard Required Provided Providcd Required Provided 1.6 Water Supply:(M.G.L c.40,§54) e Information: 1.8 Sewage Disposal System: utside Flood ZoneT Munici d O On site Jis sal s stem ❑Public❑ Private❑ Check 1f es❑ p y SECTION 2. PROPERTYOWNERSHiPI` 2.1QQ1 nertofRecord' 6S q 4© U$.tz�, rPr. 1;LA G A t E]"1 r V"1 to W� me(Print) City,State,ZIP I dtS�Y,LANs7 `J�• 9)a No.and StreStreet Telephone Email Ad •ss SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolitiun ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify- Brief Description of Proposed Work-: k-5uzL,,x*)C, iq IX x OF rjcusF' SECTION a: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item Labor and Materials I. Building S 1. Building Permit Fee:5 Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Costa(item 6)x multiplier x 3.Plumbing S i�Qther Fees: S d. Mechanical (HVAC) S List: �GU� i.Mechanical (Fire S Total All Fees:S SLIP ression) Check No._Check Amount: Cash Amount:_ 6.Total Project Cost: S R� ❑Paid in Full ❑Outstanding Balance Due: t y T A SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder List CSL'rype(see below) Nu.;rad Street Type Description . U Unrestricted(Buildings tip-to 35,000 cu. Il.) R Restricted 1&2 Family Dwelling Cityfrown,State,"LIP M Masonry RC Rooting Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation De Tele hone Email address D molition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration]iw IIIC Company Name or HIC Registrant Name No.and Street - Email address Ci /Town,State,ZIPTelephone SECTION 6:WORKERS'CONIPENSAT[ON 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 Ishuance of the building permit. Signed Affidavit Attached? Yes ..........❑ No...........❑ SECTION 7a.OWNER AUTHORIZATION,TO BE.COMPLETED,WHENd OWNER'S AGENT Olt 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 Name(Electronic Signature) Date SECTION 7b:OWNEW ORAUTHORIZED AGENT DECLARATION By entering my name below,)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. L �sLc;aM Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: I. 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 II.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass.eov'oea Information on the Construction Supervisor License can be found at wwvv.mass.^ov-!Irs 2. When substantial work is planned,provide the information below: rolal floor area(sq. R.) (including garage,finished basementlatlice,decks or porch) Gross living area(sq. RJ Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths 'rype of heating system Number of decks/porches 'rype of cooling system Enclosed Open___ r 1. "Total Project Square Footage"may be substituted fur"Total Project Cost" II . . I � �, i I, II'j�! 1 fF n� , �. `� j�a ✓ � � �exwrisaicmereeis`raw'r a a it s, �..\;L I CLr 1r-0222 17-9221 �y7tS T 17-0235 17-0234 17-0292 r�fY R4 t7-22''3 ST-0236 17-0241 a2 �, t7-0237 i r' 17-0239 / R / 17-0e7E ,7_0238 r ;7-o24a r� MRX�MUM (� cW�tnc�c 31lZ sa v=r 357° (m %tLb,lks) QTY OF SALEM, MASSACHUSETTS .1, N BUILDING DEPARTMENT _ 120 WASHINGTON STREET,3A0FLOoR TEL(978)745-9595 KRaERLEYDRISOOLL FAX(978)740-9846 MAYOR THOMAS ST.PIERRE DIRECTOR OFPUBLICPROFER7Y/BUILDING00M OSIONER 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 00, S 54; Building Permit if is with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste deposit 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: A�EJti ��Aas�L�2 rrr�z-so� (name of facility) �wc�r-wa (address of facility) Signature of applicant Date 1 QTY OF SALEM, MASSAa USETTS BUILDING DEPARTMENT • \ t rJ1�s% 120 WASHINGTON STREET,3tD FLOOR TEL. (978)745-9595 FAX(978)740-9846 KIMBERLEY DRISCOLL MAYOR THOMAS STTIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING COMNIISSIONER HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: Date S Job Location 1 Usl iunc t> S—, , SA L- 1 6-1a Home Owner Address SAu`+E Present Mailing Address 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 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 .. -