7 OAKLAND ST - BUILDING INSPECTION r
����/�_ ---- I'he C'unnnunsveahh of M;usachuselts - .
Board or Building Regulations and Standards CI"I'Y OF
s Ntnssachuselts State Building Code, 7SO C NIR SALEM
l
lr?ri.te11.1611 dull
Building Permit Application 'ro Construct, Repair. Renovate Or Demolish a
One-ur Tm u-bami(r Dn el ing,
This Section For Otlicial Use Only /
Building Permit Number: Date Applied: g
lWilding 011icial tPrint Mum) / Sigtmlurn Dutc
SECTION 1:SITE INFORMATION
I Property Address: 1.1 Assessur blap sfl Parcel Numbers
] (`�q d V1 rd 5 _
I.la Is this an accepted street? -es no Map Number Purcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area Isq III Frontage(11)
1.3 Building Setbacks(R)
Front Yurd Side Yunls Rear Yard
ZKnt)
Provided Required Provided Required Provided
upply:(M.G.I.c. 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Private❑ Zone: _ Outside Flood Zone? Municipal O On site disposal slstcm ❑
Check if yes❑
SECTION3: PROPERTY OWNERSHIP'
f Record:
���\ >lc�r fi /(li IZ(A �(x ((A SCllen/)City.Stale.Z.IP
c <lavtc� klc�rt `la�u�c�
No.and Street Telephone I Address Q}
SECTION]: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) CIAlteratlon(s) ❑ I Addition ❑
Denwlition ❑ Accessory Bldg. ❑ 1 Number of Units_ Other Cl Speeir'y:
Brief De criptionofProposed Work': �r1C�� 11 �'C>hC �C� m^e KP s �SY12
df
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 0111c1a1 Use Only
(Labor and .\laterials)
I. Building s I. Building Permit Fee: s Indicate how lee is determined:
l:'Iccirical s ❑Standard CityrTown Application Fee
❑Total Project Cost'i Item 6)x multiplier _ x
i 7. I'lunihing S -.-- —
Other Fees: s
J. \lech.mic.d ill\.\O s List:.— '---- — . .
i \leehanieal iFire S —
\o y v essionl Total .\It Fees: s_
Cheek No. Check Ammmt: C,Ish \moron:
I, Total Project Cost: S 120- p0 0 P;:id in Full 0 Oulst:mding Ilakuice Due:
r ,
SE("FION S: CON5I'1111criON SERVICES
5.1 ('onstructiott Supervisur Liceuse(C SI.)
License fJunlher I�spir:uian IAue
N;u ne a l'C.11. Holder
I ist l'SI. II Pe Isee helual.__
--- ---'---- ---'-- _..---- -.._._._._- --- .I.)pe Descriplion
No. .mJ Street
U IhlrcslrielcJlBuilJin'.s,i toit,IlUUcu. Il.l
R Re,lricted LC? 1'aulil D„dlin
CiPifoo n,State.ZIP SI % ;lsun
RC Roolin Cosvhn
N'induw :ulJ SiJin
SF Solid Fuel Burning Appliances
I Imulution
l'ele hone I(nlail address D Demolition
5.2 Registered flume Improvement Contractor(HIC)
IIIC Registr liun Numher F.vpiruliun Dale
IIIC Compan) Name or IIIC i(egismmnt Name
No. cold Street Email address
City/Town. State ZIP fete hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e. 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 .......... O No...........O
SECTION 7a: 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(Eleclrunic Signutum) Dale
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.
urge- O G0010,Vt
Print Ownef i ur:\ulhnri/CJ AgC111 s NHIIW(hlectrunle.\Igmaure) DuW
NOTES:
I. :In:regi7vered
ubtains a building permit to do his.her own work,ur an owner who hires an unregistered euntrictor
t no the Hume Improvement Contractor(HICI Program), will no have access to the arbitration
proant) fund under\I.G.L. c. 141v Other impurtant information on the HIC Program can be limed at
-, i information on the Construction Supervisor License can be found at„",, ilt �r� -Ili,
2. When substantial work is planned,provide the information below:
fowl flour area I sy. B.1 . -- I including garage. finished basement.attics,decks or porcisl
--'—
Grosslivingarealsy. 11.t Habitable room count .-
\umberoflireplaccs ._. \umherol'bcdrooms .. _ -. . .
1 \wnher of hathroums -- _. .. J_ \unlbtt ul'half oaths
I\pe of heating s),Iem - . . _ \lumber of decks, porches
1\pc of wading stem _ Foclosed .Open
t. "roial Project Square Foolage"n%1% hc.uh,wutcd Il,r"Goal Project CoA'*
x
CITY OF SM.EIM
PUBLIC PROPERTY
DEPARI',IENT'
vwrae t at►v s,s.ar•sKa,w wn�oasms a»'o
n&9-V45.95"•F.4a.V8.74696ae
HOMEOWNER LICLNSE EXEMPTION
P1esw Fries
Job coeatios
Home Owner Address I c
Home Owner Telephone CV)-% -)U l_
Present Mailing Address :VVP
The cusent exemption of"Homeowner"was extended to include owner-occupied
dwellings ottwo units or less and to allow such homeowners to engage an individual for
hire who.does not possess a liemso provided that the owner act@ as supervisor.
DEFINITION OF HOMEOWNER
Pe sons) who owns a parcel of land on which he/she resides or intends to raids. on
which there is, or is intended to be,a one or two tinily dwelling, attached or detached
structures accessory to such use and/or farm structures. A person who constructs more
dun one home in a two year period shall not be considered a homeowner. Such
"ttorrteownes"shall submit to the Building Official,on s 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 procedures and requirements and that he/she
will comply with said procedures and requirements
HOMEOWNERS SIGNATLIM Q� c_ SLC vL3
APPROVAL OF BUILDING NSPECTOR
See other side for state code