22 OAKLAND ST - BUILDING INSPECTION �� SJ The Commonwealth of Massachusetts Town of
f I , Board of Building Regulations and Standards
Massachusetts Stale Building Code, 780 CMR, T"edition Building Dept
m
\ Building Permit Application To Construct, Repair, Renovate Or Deolish a
One. or Two-Famils Duelling
This Section For Official Use Only
Building Permit Number: - D I Applied:
Signature:
t Budding Commissioner/InspecicirW Buildings ffU bate
SECTION 1:SITE , FORMATION
1.1 Property address: g� 0.6i'viwd �,t. 1.2 Assessors Map k Parcel Number
1.1 a Is this an acce led street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning Distnct Proposed Use Lot Area(sq ft) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L.c.40.154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Munpal❑ On site disposal system ❑
Public❑ Private❑ Check if vesO
SECTION 2: PROPERTY OWNERSHIP' ,�J
2.1 0-n trade t'd •
Na int), Address for Service:
Y7-$� -
Signature Telephone
SECTION l: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. O Number of Unita_ Other ❑ Specify:
Brief Description of Proposed Work': -
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Ooly
Labor and Materials
1. Building S 1. Building Permit Fee: f Indicate how fee is determined:
Standard City/Town/Town App
licationFee
❑S ry PP
2 Electrical f
❑Total Project Cost (Item x
J Plumbing S 2. Other Fees: f
4. Mechanical (HVAC) S List:
t Mechanical (Fire S Total All Fees. f
Suppression)
Check No. _Check Amount: Cash Amount:_
h Total Project Cost S l5 �� ❑ Paid in Full O Outstanding Balance Due
�d 5
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
r.
• License Number Espmauon Dam
N,poe of CSL Ifgkkt List CSL Type lx'o below)
Is Address T' Description
U I Unrestricted i up to)5,000 Cu. Ft.
0. I Restricted 1&2 Family Dwelbn
Signature M sclawnry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
Ste I Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.1 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 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Owner of the subject property hereby
1, as O J P PenY Y
authorize to act on my behalf,in all matter
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1, ,as Owner or Authorized Agent hereby declare
that the statements and ' rmation on,,"foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
Signed under the pains and penalties of perjury)
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 @&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 I MR6 and 110 R.S, 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 heating system Number of deckv porches
Typeof cooling system Enclosed Open
3 "Tool Project Square Footage-may he substituted for"Total Project Cost"
CITY OF S.ULE.NI
PUBLIC PROPERTY
DEPARTMENT
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HOMEOWNER LICENSE EXE.r1PTI0N
MAN "t
Date
Job Location
Home Owner Address
Home Owner Telephone IP.9.Sd
Presaot Mailing Address bay
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 who does not possese 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 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.HO.MEOWYER L
S SIGNATURE 9
APPROVAL OF BUILDING INSPECTOR
Sce other side for state code
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
ra\IIA HI h.1'I'It h1.1'1 I.
U ,t nt 120W.\stu.\(;:ouSIBEET ti.\mM, M,wi,%tIn 'irIsulw�
Fri:978-745Ai95 • FAX:978-740-9846
.L
Construction Debris Disposal Affidavit
(required fur 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 # _._ 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
I11. S 150A.
The debris will be transported by:
/V O )e V.—Si
(name of hauler) _
The debris will be disposed of in
(name of faci ity)
(address of facility)
W�
signature of I n//it applicant
to
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