27 OAKLAND ST - BUILDING INSPECTION � 2S CAS LA
The Commonwealth of blasseehusetts
�,P���3�� tr�1'iF
� Board of Building Regulations and Standards SALEM
qYt / Massachusetts State Building Code,780 CMR R isbiµµy�2011
l• , Building Permit Application To Construct, Repair, Renovate Or DfthdtlSh
One-or Two-Farnily Dwelling
This Section For Official Use Onl
Building Permit Number: Date Applied:
- Sig.oture - Date
T Building Olficial(Print Name). - .' _ n '
_n SECTION t:SITE INFORtVIATIOW
1.1 Property Address: 1.2 Assessors blap&Parcel Numbers
a� GaK-w-al �Y
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq lt) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
ReyuireJ Provide) Required Provided Required Provided
1.6 Water Supply:(M.G.L c.d0,§Sd) 1.7 Flood Zone Information: Lg Sewage Disposal System:
Zone: Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ — Check if yesO
SECTION2: PROPERTY OWNERSHIP!:
2.1 Owner"of Record:
IAGli;Aiu\ c�y6V-V �c,Ae M MA U lR7y
time(Print) City,State,ZIP
9-`i Oc Ve \.c. -A Sar Dgv_Kfl,&4 0
No.and Strcct Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) J¢L Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work-:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials)
I. Building $ I. Building Permit Fire:$ Indicate how fee is determined:
❑Standard Cityfrown Application Fee
2. Electrical $ ❑Total Project Costa(Item 6)x multiplier
3. Plumbing S ?. Other Fees: S
d. Mechanical (HV;1C) S List: `
5.,Mechanical (Fire S Total All Fees:S
Su ression)
Check No._Check Amount: Cash Amount:_
G. To MI Project Cast: S SW ❑Paid in Full ❑Outstanding Balance Due:
\_A O • llt�12y
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
""r :.) ? F, i (`; License Number Expiration Date
Name of CSL Holder List CSL"type(see below)
Type Description
No.and Street .
U Unrestricted Buildin a to 35,000 cu. It.
R Restricted I&2 Famil Dwelling
CityRbwn,State,ZIP M Masontry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulotion
Telephone - Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
IIIC Company Name or(IIC Registrant Name
i
No. and Street Email address
Cityrrown,State ZIP Tel e hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L:c. 152.1 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 ..........❑ No........... O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN..
OWNER'S AGENT OR CONTRACTORAPPLIES FOR BUILDING PERMIT
1,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 OR AUTHORIZED AGENT DECLARATION
i
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.
[Q"GC.T- t6
Pma 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 ngr have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
+e+v+v mass.euv'oca Information on the Construction Supervisor License can be found at wh+�'dos
2. When substantial work is planned,provide the information below:
rolal fluor area(sq. ft.) (including garage,finished basementlattics,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 decks/porches
Type of cooling system Enclosed Open
3. -fotal Project Square Footage"may be substituted for"'total Project Cost"
I
I
QTY OF SALEM, MASSAC HUSE TTS
BUILDING DEPARTMENT
120 WASHINGTONSTREET,3"OFLOOR
TEL. (978)745-9595
KLV MERLEYD1USCC)LL FAX(978)740-9846
MAYOR THows STAERRE
DIRECTOR OFPUBLICPROPERTY/BUILDING CONSUSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT.
Date LL C.\ J&
Job Location X? dCq_w'-gk 2)�—
Home Owner Address
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'SSIGNATURE s006"
APPROVAL OF BUILDING INSPECTOR
alYOFSALEM MASWISEn
BanUMDarARnOrr
120 We=w7avS7a W 3'DFL=
HD�ERilYXLFear 7f098�6
MAYOR 1tioausS7.P
DmK3mcrrtsurc /awVEWalaffMaND
Construction Debris DisposaiAff'rda►vit
(required forall demolition and,.renovation worki
In accordance with the sbrth edition of the State Bugling Code, =OUR, Secdon 111.5 Debris,
and the provisions of MGL co,S S4, NdidkW permit B is wed with the
condion that the debris resu ft from this work shag be disposed of in a properly licensed
waste deposit facility as defined by MGL c 11i,S 15 &
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
Date