22 OAKLAND ST - BUILDING INSPECTION (2) j The Commonwealth ul'Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7'edition OF SALFM
�r� NrvisrJJumrolr •
Building Permit Application To Construct, Repair, Renovate Or Demolish a
or Two-Family Dwelling
This Section For O.frcial Use Only
CN //y Building Permit Number: Date Applied: V
Signature• ,Z�/2�U�1
Building CommrssioneN Inspects ur Buildings Dole
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
1,-i ocy-)A - cbvee--t-
1.1 a Is this an accepted strect?yea no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Ls Area(sq 11) Frontage(11)
1.5 Building Setbacks(R)
From Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Public Cl Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record•
t�1avlyy6- OVIL� S„�s� -
Name(Print) Address fs Service:
/��?l➢1r.(A,' — -111A C0,4A— q7k 8�7 S-7'37
Sign rR Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check ag that apply)
New Construction❑ Existing Building❑ Owner-Occupied O Repairs(s) O Alleration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work': Ir iit " fYl Len
CAaG ' d
Ci
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 011lelal Use Only
Labor and Materials
I. Building S O p(� 1. Building Persil Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical s ❑Total Project Costs(Item 6)x multiplier x
3. Plumbing S 2. Other Fen: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No. _Check Amount: Cash Amount:
6. Total Project Cost: S "7 p'� [� O Paid in Full 13 Outstanding Balance Due:
SECTION 3: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
L iccrre Number lispimtiun Date
Name ol'CS''1.• I lulder I.iA C.
rype Isee below)
r Description
re
Address U I InstricleJ to 35,000 Cu. Ft.
R I Restricted IA2 Family Dwelling
Signature M= I mg2n Only
RC Reiidential Roolin C'overin
rdephone I WS I Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Inslallalim
D I Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or IIIC Registranl Name Registration Number
Address Espiratian Date
Sigruoure rdeplu'm
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. IS2.f 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 ..........O 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.
r(Siwwa-undff
Owner Dote
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
)y[ a I"L �c7 V Ste_ ,as Owner or Authorized Agent hereby declare
ements and information on the foregoing application are true and accurate,to the best of my knowledge and
In f14�to
Owner or Au h 'zed Agent Date
r the pains andesenaltics of 'u
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 rag have access to the arbitration
program or guaranty fund under M.G.L. c. 1 42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations I IO.R6 and I MRS.respectively.
2. When substantial work is planned,provide the information below:
Total Floors area ISq. 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
Type of cooling system Enclosed Open
). "Total Project Square Footage" maybe substituted for"Total Project Cost"
CITY OF S.U.E.Nt
PUBLIC PROPERTY
DEPARTtitENT
u,ouur ersraaL
M.+�. I-3GWM DWT Manaxr9SAL04MAaAO&MMIat9'0
ru-9'8-715.9599 9 P.uL 9'8.74&9W
HOMEOWNER LIMNSE EXEMPTION
lhew IMnt
Dan 10 lQIto
Job Location 9 2- F)Q L
Home Owner Address ;a;;a;L 0 a VX cwd S
Home Owner Telephone 79 r'S 7 S-F 7
Present Mailing Address ?-a- U eOU av�aC
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or lea 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 HOMWWNE t
Person(s)who owns a passel offend 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
structurn aeeesaory 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
"lomeownce shall submit to the Building Official, on a fora acceptable to the Building
Official, that he/she be responsible for all such work performed under the Building
Permit
The undersigned "homeownee assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeownee certifies that he/she undentands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
wilt comply with said procedures and requirements.
HO.tEOWVERS SIGNATURE
APPROVAL OF BUILDENG NSPECTOR
See other side for state code
CITY OF SALEM
PUBLIC PROPRERTY
;4 ;.
DEPAR NIENT
. •.1 'i I:; \\ �+III\i..,".11!L1 r • ,,\II \I,
Construction Debris Disposal Affidavit
(required lbr all demolition and renovation work)
In accordance ill, the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of v1GL c 40, S 54;
Building Permit it 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 iv1GL c
t 11. S 150A.
The debris will be transported by:
-
' I name of hatdar)
The debris will be disposed of in
(nalnr of facility)
1❑ddrcss lit IarllilV)
.Ignaturc of pirn .Ipphranl
iDll `L
,lace