30 OAKLAND ST - BUILDING INSPECTION The Commonwealth of Massachusetts
,_ i ,;, Board of Building Regulations and Standards H)R
%II;Nl( 111ALI I )
Massachusetts State Building Code. 780 C'MR. 7°i edition I IS 1:
Building Permit Application To Construct. Repair. Renovate Or Demolish a Krri,rJ./,nnm,rt
One- or Tn ttih. Duelling 't 0S
T s Section Ft r Official Use Only
Building Permit Nm ber: Date Applied: _—
Signature: L C 30
in 11 CUIlrlrl1S iouel'/ Ins )r of it I it Dal
S . '"' 1: SITE INFORMATION
LI Property :address: 1.2 Assessors Map & Parcel Numbers
30 oA KIANt7 s>. SALEnti Ma 6070
I.la Is this an accepted street?yes__ no-_- Map Number Parcel Nmnhel'
1.3 Zoning Information; L4 Properly Dimensions:
Zoning Distract Proposed Use Lot Area(sy Ill _ Frontage tit)
r 1.5 Buildin;;Setbacks (ft)
'wont Yard Side Yards Rear Yard
i -
�-- Required Provided Reyuircd Provided Required Pn,vidcd
hi.6 Water Supply: (b1.G.L c. 40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Check i F yes❑Zone''
Public ❑ Private 0 — Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP[
2.1 Ownerl of Record:
jo c7AKs-A NtI. SC'_
Na Tint) Address for Service:
_ q_16 -7q S 0(,1f7, _
S—ign-at-- ----- Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑� Existing Building ❑ Owner-Occupied ❑ Repairs(s) Alteration(s)XI Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specily:
Brief Description of Proposed Work': eLAC.£ 011p ,SzWA ANrD(4A1L_ svr e�.- 1-.P6
( Tl4 'PR€SS�2t- 'C1ZEATE1> ."Lt kM%E;?, CS-, E t02� Otv '?�y-r11 0,00- PoeLF1
StpE �c A 2wany EI Z"1 r9LL STW(P_wA`1 S l f�A-rt7 "rc- FLAG 10(k
-
SECTION 4: ESTIMATED CONSTRUCTION COSTS
f Estimated Costs: -- _- --_---� ---
Item (Labor and Materials) Official Use Only
1. Building 5 O� 1. 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 5 2. ,2! '
t- Other Fees: $���c.�
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire S
Total All Fees: S
Suppression)
Check No. Check Amount: Cash Annnntr: _
b. 'Fotal Project Cost: $ 25O 0 Paid in Full 0 Outstanding Balance Due:__.___
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) r
License Number F\pilation Dole -.
Namc of CSL- (Holder
List CSI_ 'P)pe(see below)
\ddress T, III Descri)(ion
C Unrrsuicled top to 3i,000 C LI. FI.t
R Restricted I&'_ Family Dwelline
Signaulre .M %laionry Only
RC Residential Rooting Co,enne
Telephone Residential Wi rld'm .Ind Sidme
PT" �
Rc,idrntial Sul id Fuel liurnule \ ++li:mce In st all.t u,u Residential Demolition
5.2 Registered Home Improvement Contractor [HIC)
HIC Company Name or HIC Registrant Name Registration Nlllllher --
Address
Expiration Date
.signature Telephone
�—SECTION 6: WORKERS' C.OMMNSA"I tON [INSURANCE AMFIDA Vi T (1vi.G.L.(: i52. y 2SC16))
I
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
1, J�F2EM`i 'Tv nIDA , as Owner of the subject property hereby
authorize ti"-1 to act on my behalf. in all matters
relative to work authorized by this building permit application.
-- — --- -- 7 2,_z
wDate
- —
Sienare of nee U --------
SECTION 7b: OWNER' OR AUTHORIZED AGENT
i±ENT DEC LAATION
as Owner or Authorized Agent hereby declare
that the statements and information on the 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 periury)
NOTES:
1. 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 at bitrtiun
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing (CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS, respectively.
- When substantial work is planned, provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attica, decks or putchl
Gross living area(Sq. Ft.) Habitable room count _
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halt/baths
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"
CITY OF SALEM
' y PUBLIC PROPRERTY
' DEPARTMENT
11 q; 12Z \\.\iI II\I„iN SC?l.rr ♦ !).Al l III, %I.Ili\l I .� :I')
1),8-N?- ;95 1 vx:1)-8 74-.9141,
Construction Debris Disposal Affidavit
(reyuircd li)r all demolition and renovation work)
In accordance I,,,ith the sixth edition of the State Building Code, 780 CMR section 1 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit H _ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal lacility as defined by MGL c
1I1. S I50A.
The debris will be transported by:
)v n 2 H S I F C'i1R2+l Q 6-
(name of halter)
I lie debris will be disposed of in
(name of-lacility)
js � MPSc.oIvvr'
(address ul'Ihcility)
♦l_llatul' )f IKrn It .11) (cant
22 O
Icl.i i.,ti d,�
CITY OF SME-M
PUBLIC PROPERTY
DEPARTMENT
K, 0ancaLL
VAry 130 VA"NM M S711ear•SALdK NASA[NL3tfls 01970
TF1.97.L7i5.9S95 • FAX 97 -74&9&0
HOMEOWNER LICENSE EXEMPTION
Pfease filet
Date 112 21 0 6
JobLocadoe PR,+ i4¢1 R�S,C�N
Horne Owner Address 36 o o sr sP,--eAA Ma, o k q'16
Home Owner Telephone 1 1 g —T ti s O b 4 3
Present Mailing Address �E
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 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 dwellin& attached or detached .
structures accessory to such use and/or fans 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 O®ciaL 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 SIGNATI,'RE
,APPROVAL OF BUILDCYG (INSPECTOR
See other side for state code