30 OAKLAND ST - BUILDING INSPECTION (3) M STrpm
D,
,7 the C'onunomveahh of Massachusells
Hoard uFlluilding Regulations and Standards CI VY OF
SALEM
Massachusetts State Building Code. 780 C NIR
Rerised.Ihu•'0/l
Building Permit Application 'ro Construct, Repair. Renovate Or Demolish a
One-or Tivi)-Famil.v Dtrellmq
This Section For Olficial Use Only
Building Permit Number: _ Date Applied:
_ >� 7 -
IuilJing Ullicial(Print None) .'igna ure Dwc
SECTION I: SITE INFORMATION
1.1 Property Address: 1.2 Assessors blap& Purr Number
3o Oalctana, SI
I.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District I'mpused U.w Lot Area(sq III Pmntuge(Ill
1.5 Building Setbacks(R)
Front Yard Side Yank Reor Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40.§Sq) 1.7 Flood Zone Information: 1.8 Sewege Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Check if cs❑-Lone? Municipal❑ On site disposal s)stem ❑
• SECTION3: PROPERTY OWNERSHIP'
2.1 O nett of Record
Mane(Print) I City,Slate,ZIP
Yo Oa �G(ati d S+ teleph 4� R64 6�1G lerc� t�o @5��oocd_
Nu.and Street one Finail Add
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specq:
Brief Description of Proposed Work':
Fxleitd -eu-, S-+�nE Jz&lr S4eA —
SECTION a: ESTIMATED CONSTRUCTION COSTS
liv,ll Estimated Costs: Official Use Onl
(Labur and Materials) y
I. Building S 1. Building Permit Fee: S Indicate how lee is determined:
'. (electrical S ❑Standard CityvTuwn Application Fee
❑Total Project Cost'(Item 6)x multiplier _._— x
!. Plumbing S Icr,
. Other Fees: S_ - - - -
J, >lech.ulical ,II\'.\(') S ist:
5. .\lalt.mical iF,re S -
\n i ReSYiJn) otal .\II Fees:
heck Nu. ('heck Antoum: _ Cash 4m,mnl:
n Tidal Project Cush S 20 pPaid in Full 0 Outstaoding 11.1l;utce Oue:
SEC"['ION 5: CONS I'Itlic'noi,4 SERVICES
5.1 ('onstructioit Super isor License((Si,I
vintlion Date
jcQnse Nomb�r
Ninne ofi,SI I loldcr I is[L SI. I)ric Isev b6m I
1*\PC Dcseriplion o In It
I
if unrcsvict�d(Iloildinp Lin to 35.000,u It I
c in
liestrictcd 1&2 1.111111% 0%%cllioll
S(atc,/111 Mason
RC Roolin CoNcrin
Nk S and SJU111"
S d 111, 11", 's
SF Solid I:ucI[fuming Appliances
I I'Listilation
inollln
I elcyllone Finail address D Demolition
5.2 Registered Home Improvement Cunirnclor(HIC)
IIIC Itcgibiriflion Number F\pirmion Date
I IIC Compan) Name or I IlC liegistrual Ninin:
No. and Street Email address
CityfTown, State,ZIP relephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 132.1 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 Affldavit Attached? Yes .......... a No...........0
SECTION 7s: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 Uwner's ne(Electronic Signature) Date
SECTION 7b:OWNEWOR 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 true and accuralcito the best of my knowledge and understanding.
Daw
NOTES.
I. An Owner who obtains a building permit to do his,her own work,or an owner who hires an unregistered contractor
I "o inut registered in the Hume Improvement Cuntractor(HIC) Program),\villjU) have access to the arbitration
o registered
program or guaranty fund underM.G.L.c. 142.A.Other important information on the HIC Program can be found at
www _ , � 'I
11,1'.1 0k.1 Information on the Construction Supervisor License can be found at 1%w% till- �;o^ fit,
o .
2. \%hen substantial\%ork is planned, provide the information below:
Total flour area I iq. 111 1 including garage, rinishcel basement attics,decks or porch?
Gross IN ing area(sq. it,I Habitable room count
Number ol'bedroonis
Number ofliall b-ill's
Ntiniherot hathrooms
1\Ile Lit heating '),1011lp
Nnnihcr o(Jecks, pordies
Project Square Fool,lcc 111as he itib,tituicd l'or I'ol.d Project Cast"
CITY OF SMS—M
PUBLIC PROPERTY
DEPART,LENT
KJ10�Ya1/n�ryw
.Vw�va 130 WAWNGWl araaar•&MJ^VAUAo1LSWMOW*
HOMEOWNER LICENSE EXEMPTION
Flew Frbt
Date u L
Job Locados O a f cCa h d ��-
Home Owns Address s� e
Home Owns?elephooe I'] 8 b 9 4 9 /6
Preset Mailing Address :f5c-M v
no current exemption of"Homeowners"was esterded to include owneroccupied
dwellings of two Units or feat and to allow such homeowner$to engage an individual for
hire who does not possess a license,provided that the owns act@ a.supervisor.
DEFINITION OF HOMEOWNFA
Person(s)who owns a parcel o[land on which hdshe resides or intends to reside. on
which there is, or is intended to be,a one or two family dwelling,attached or detached
structure$ 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'shag submit to the Building Omcial,on a form acceptable to the Building
Official, that he/she be responsible for all such wort performed under the Building
Permit
The undersigned "homeowner assumed 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 said procedures and requirement*)
HOMEOWNERS SIGNATURE APPROVAL OF OF BUILDING CiSPECTOR '
See other side for state code
CITY OF S.u_Eaf, NLlss.kcHL:sETTS
JLtLOLYC OEFAATLIUNT
110 WASKNCTON STXSRT, 3w EtCCIt
121. �97� 74S-9S9S
F.Vt(978) 714994d
KI1COBA►EY OUXOLL
MAYOA 11iO.�N!SL P[F11s
011=011 OF PL SUC PR0P1!F1TY/9CMDLY43 CO\L%ItSSION EI<
Construction Debris Disposal At'ttdavit
(required for all demolition and renovation work)
In accordance with the sixth edition Of the State Building Cade, 790 CMR section I I I.3
Oebris, and the provisions of WE a 40, S 34;
Building Permit 4 is issued with the condition that the debris resulting From
this work shall be disposed of in a properly Iicemed waste disposal raciIicy as defined by NICE c
I If, S I JOA.
The debris will be transported by:
(name ot'hauler)
The debris will be disposed Orin
�{ t �St
(name of(acdi y)) )
(iddrets orrwilny)
u�nanr afpermitrpphcint
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