19 OAKLAND ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 C'MR. 7i°edition OF SALEM
'war Revised Junuurr
Building Permit Application To Construct. Repair, Renovate Or Demolish a I. :141
One-or rtvo-Family Dwelling
This Section For Official Use Only
Building Permit No be Date Applied: p
Signature: U14110
Building Commissioner/Inspector of Buildinip Date
SECTION I:SITE INFORMATION
).1 Property Address:�,�! 1.2 Assessors Map d1 Parcel Numbers
19 OhI4,hrin S�Yeer
1.la Is this an accepted street?yes no Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Pmpowd Use Lot Area(sq It) Frontage(11)
1.5 Building Setbacks(ft)
From Yard Side Yards Rear Yard
Requited Provided Requited Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public O Private O Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Check if eso
SECTION 2: PROPERTY OWNERSHIP'
r:Sisn_,t4u- '
r'of Reco d:
r gG�r/Gr9H/9k
Address for Service:
Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
uction O Existing Building O Owner-Occupied O Repairs(s) O Alteration(s) O Addition O
Demolition O Accessory Bldg.O 1 Number of Units_ Other O Specify:
Brief Description of Proposed Work=:
LS:a 7706T
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 011lclal Use Only
Labor and Materials
I. Building is I. Building Permit Fee:f Indicate how tee is determined:
�. Electrical S O Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC► S List:
5. Mechanical (Fire S
Su ression Total All Fees:f
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S /(�J 0p Paid in Full ❑Outstanding Balance Due:
77 C�
CONSTRUCTION SERVICES
r�-7—�SECT�IONS:
onstruction Supervisor(CSL)
license Number Expiration Uatelder ListCSL Type(seebelow)
f Descri ion
U I.Inresiricted u to 35,000 Cu.Ft.R Restricted IR2 Famil Dwellin M M only
RC I Residential Roolin Coverin
1'eieptarne I Residential Window and Siding
SFI Residential Solid Fuel Burning Appliance Installation
DI Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or)IIC Registrant Name Registration Number
Address Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.f 23C(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 /2a 8 .,f C h4811-,!F J1/�, - , as Owner of the subject property hereby
authorize N&Cj, 1ght ir1717k , -1-!7 - to act on my behalf,in all matters
relative authorized by this building,permit application. - h
signioure of Owner Dote
SECTION 71b:OWNEW OR AUTHORIZED AGENT DECLARATION
I ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application arc true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of(honer or Authorized Agent Date -
Si under the ains and rtalties of 'u
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.W have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I IO.R3,respectively.
2 When substantial work is planned,provide the information below:
Total floors 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 half/baths
Type of healing system Number of decks/porches
T)peof cooling system Enclosed Open
J. "Total Project Square Footage"may be substituted for"Total Project Cost"
i
CITY OF SM.E.Ni
PUBLIC PROPERTY
DEPARTMENT
w,ar,.r o.n
%"VON 130 W.�uw�d 4nrsr•S,►AK%UUAC LsrM 01910
fl3.9-a-74S-95"• Fix.978.74&9&4
HOMEOWNER LICENSE EXEMPTION
Pkue Met
Date-7 as 0/ 1)
Job Location J 9 C14 -
Home Owner Address ca A4
Horne Owner Telephone 9 -7 r C-717%r S'
Present Mailing Address
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or lest and to allow such homeowners to engage an individual for
hire who does not possess a license,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 dwellin& 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE
,APPROVAL OF BUILDING INSPECTOR
See other side for state code
{ CITY OF SALEM
Sb~ ' PUBLIC PROPRERTY
DEPAR"I'MENT
12�%X N\ lII.Nt. IN*m RIAT ♦ Snl I M, %I Nli.\, ❑ ;I I ,',i l't
I I : v73.7459;')5 • I n\: 1)84,i
Construction Debris Disposal Affidavit
(required lbr all dennolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 1 1 L5
Debris, and the provisions of MGL c 40, S 54;
Building Permit 9 is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I 11. S 150A.
The debris will be transported by:
_ - (name of hauler)
The debris will be disposed of in
4c4 it yf of fa I�tyPI
(address of facility)
s ienaturc of permit applicant