30 OAKLAND ST - BUILDING INSPECTION (2) if 1 I-t3 - IK -- cr- z1 ( 250V
N� The Commonwealth of MassachusettsI ECE O QF
r�r Board of Building Regulations and Standards INSPEC IONA1,A�.�;M1�t►ICE
`h Massachusetts State Building Code, 780 CMR
i Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or DemoQ814a _q A 13 21
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name) Signature ate
SECTION 1:SITE INFORMATION
1.1 Property Addrerss: / 1.2 Assessors Map& Parcel Numbers
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1.1 a Is this an accepted street?ves no Map Number Parcel Number__
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq fl) Frontage(n)
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,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
_ Check if yes❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Qwner'of Rprd:
Prs u o K a14 _ Jer err MA U'/q'�-O
Name(Paint)/ / City,State,ZIP
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�J (JQ.0�2Ha' �r" /ter�� d°�% Ei l�d P2'/t'r -"n/X�l`�ciGnnC i c•
No.and Street "relephone Email Address-"
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Speedy:
Brief Description of Propos Work:
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SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ O
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing $ pp 2. Other Fees: $
4. Mechanical (FIVAC) $ List:_
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ ���0 ❑Paid in Full ❑Outstanding Balance Due:
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
t' S .8 N P_ 6 L'L 01 List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu. 11.
R Restricted 1&2 Family Dwelling
City/town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
� HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town, State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 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 .......... O No ...........❑
SECTION 7a: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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is nd accu� to the best of my knowledge and understanding.
lever j FJC 6 9 .Zn/
Print OwnLfOs or Authorized Age s Nan e(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 not 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
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/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 hal0baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
J . %"`°=� CITY OF SALEM, MASSAC IUSETTS
BUILDING DEPARTMENT
�\ 120%VASHINGTON STREET,3"D FLOOR
\ ,Yx TEL. (978) 745-9595
FAX(978) 740-9846
KIMBERLEY DRISCOLL
MAYOR TI-IOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CON[NIISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date 97,01 y
!/ / c J' \
Job Location 3� KlanO 1 qA
Oa 4 !ryn
Home Owner Address '70 00 IC (4 �4rrle A/f
Present Mailing Address 36 Oa L/&-7 d S T .J4 ll. /r1,+
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
Personls) 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'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR
J
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CITY OF s,v—E1,[, LtiL1SS:ICHUSE-I
1 . ,( S
ElUILOLNG DEPARTNLF,NT
w h,T',n
.' 120 CU.ISHLYGTOV STREET, 3w FtOOR
TEL (973) 715-9595
KIMBERLEY DRISCOLL FAA(973) 7-W-931S
LiYO2 7`to�c�STFt�wss
DIRECTOR OF PUBLIC PROPEQTY/8CLLDDIG CO\LNHSSION EA
Cormtruction Debris Disposal Aff7davit
(required for all demolition turd renovation work)
In accordance with the si.eth edition of the State Building Code, 730 CD,IR section l t I
Debris, and the provisions of tXIGL e 40 S 5 • 5
Building Permit # � �'
this work shall be disposed of in a properlyis tlicensed waste dispos with tile al that the debris resulting from
I 11, S 150A, facility as defined by tti1CL c
"l'he debris will be transported by:
y
(IdI11C of lta r)
The dchris will be disposed of in
_-----(-.11IJres.t of tacility)
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