28 OAKLAND ST - BUILDING INSPECTION the Commonwealth of Massachusetts ---- - —
`} Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised.tlur 201l
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Fennilt,Dwelling
This Section For Official Use Only
Building Permit Number: atatte Applie : _
,lo
Building Official(Print N rne) Signature Date
SECTION 1: SITE INFORMATION 41
.I Property Address: 1.2 Assessors Nlap& P eel Numbers
!? o�'l�Lr4tNr� 5
I.la 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 11) Frontage(If)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Requied Provided Required Provided
1.6 Water Supply:(M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check ifycs❑
SECTION 2: PROPERTY NERSHIPI
Owner)of Record:
Nat me(Print) atc,Oil/y, ZIP
�
7 4T UJ/g1cL.xr..� S-"� at -2 —S�ly-oS�� 401
No.and Street "telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ .Accessory Bldg. ❑ 1>dm er of Units Other ❑ Specify:
Brief Description of Proposed Work': - C,� ejojN5 19 ROOT
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
1. Building $ I. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: $
q. Mechanical (HVAC) $ List:
5. ,Mcchanical (Fire $ - —.
Suppression) Total All Fees: S
) � Check No. _Check Amount: Cash Amount_____
G. Total Project Cult: $V Oa ❑Paid in Full []Outstanding Balance Due:
W L_
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
I.icense Number Fxpiration Date
N;une of C'SI. I(older
List CSL'r)pe(see below)
No, and Street Type Description
II Unrestricted(Buildings no to 35,000 cu. 11.)
R Restricted 1&2 Family Dwelling
Cityffown.State.ZIP M Mason
ry
RC Roolin Covering
W'S Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone ('.mail address D Demolition
5.2 Registered home Improvement Contractor(HIC)
I IIC' Registration Number Expiration Dale
I IIC'Company Name or I IIC Registrant Name
No.and Street Email address
City/Town, State,ZIP Telephone
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...........❑
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(Electronic Signature) Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By a Bring my name below,1 hereby attest under the pains and penalties of perjury that all of the inform n
con ained in this application is true and accurate to the best of my knowledge and understanding.
12ol3cny- �/20�2�1I
Print 0%%ner's or Authorized Agein's Name(Elearonic Signature) Dale
NOTES:
I. An Owner who obtains a building permit to do hisiher own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 1 q'_A.Other important information on the HIC Program can be found at
gov hea Information on the Construction Supervisor License can be found at tt t)w o� dps
2. When substantial work is planned, provide the information below:
Total floor 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
1)pe of heating system Number of decks,porches _
---------------- -- ------------
1)peofeuolingsystem Enclosed __-_—_-- _.-
3. "Total Project Square Footage'may be substituted lbr Total Project Cost'
CITY OF S.UENI
PUBLIC PROPERTY
DEPARTMENT
u.a...ar o.euat
wro. 130w gruff SAtaat,NwttuoasaMett'e
ra.f'L746i9Na•FAA 97&7169e4
HOMEOWNER LICENSE EXE.rIPTION
Pleaee"I
JobLaratim Z. an�fj� T
Ham OwnerA{RYiis Z � O'l LL RN S I .r
-
HomsOwmar?elaphone 7 -5 ✓/
Pteamt 1lfailing Addraw z s, D f G.4,-v S i— ✓/
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or lea and to allow such homeowner to engage an individual for
hire who.does not possess a licenset provided that the owner act@ as superviaot:
DEFcNMON OF HOWOWNER
Persona)who owns a parcel of land on which he/she resides or iatends 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
then one hams in a two year period shall not be considered a homeowner. Such
"homeowner'shall submit to the Building OII1cisk 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 Z.- V C/
See other side for state code
CITY OF S'U.&Nf. -liSSACHCSETTS
13LLMLNG DEPARTME.\T
' 110 WASHLNGTON STREET, 3iO FLOOR
TEL (978) 745-959S
FAX(978) 740-9846
KIJ®ERIEY DRISCOLL
MAYOR I1iow+a ST.Pmxxn
DIRECTOR OF PLBLIC PROPERTY/BUMEI IG CO\QIISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section t 11.5
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 be disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11, S I50A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
J tz V
(name of facility)
-:)-he-\-
(address of facility)
v
sigfiature of permit applicant —
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