9 OBER ST - BUILDING INSPECTION if %
t `
a the Commonwealth of Massachusetts CITY
Board of Building Regulations and Standards
1 OF SALEM
Massachusetts State Building Code, 780 CMR, T"edition
?'w� Revised Junnury
Building Permit Application To Construct, Repair, Renovate Or Demolish a
I One-or Two-Fomily Dwelling
This Section For Official Use Only
Building Permit No bee/: Date Applied:
�,
Signature: N o N tii � L
Building Commissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Add_Ees+: S�re2 1.2 Assessors Map& Parcel Numbers
C� l��iQt
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(11)
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.an,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: - Outside Flood Zone?Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
/ C / 1
Name(Print) Address for Service:
s-�>'T- .-s s
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction O Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) 13 Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other O Specify:
Brief Description of Proposed Work': rr.,-. _e r„/<<,. L
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building S 1. Building Permit Fee:S Indicate how fee is determined.-
0 Standard City/Town Application Fee
2. Electrical S O Total Project Cost'(Item 6)x multiplier x
). Plumbing $ 2. Other Fees: S
4. Mechanical (IIVAC) S List:
c
5. Mechanical (Fire S
Suppression) Total All Fees: S
Check No. Check Amount: Cash Amount:
6.Total Project Cost: S ,jQ 0 e 2 13 Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Dale
Name ul'CSL• I lolder Lisa CSL Type(see below)
r F ( on
Address U Unrestricted u ,000 Cu. Ft.
R Restricted FamilyDwelling
Signature M Masonr3ronly
RC Residential Roofing Covering
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
111c Company Name or II1C Registrant Nam Registration Number
Address Esaoatflin Date
Signature 'relephone
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 ..........0 No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 t�t x :., !v( ✓/ �� as Owner of the subject property hereby
authorize /z�— ,7. to act on my behalf,in all matters
relative to work authorized by this building permit application.
S' ?-
Signature of Owner Date
SECTION 7b: OWNERI OR AUTHORIZED AGENT DECLARATION
I ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoin ation are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature or Owner or Aulhori gent - Date
(Signed under the pains and penalties ofperjury)
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#of have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.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.
2 When substantial work is planned,provide the information below:
Total floors 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
Type of healing system Number of decks/porches
Type of cooling system Enclosed Open
J. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF SMY. Nf
PUBLIC PROPERTY
DEPARTMENT
ju,ataaar o�=s
w,�o. t]a a��.�st.Fsr•s�Nwsuoasarn 01 f'0
i41 975-745-9S99• F.%x 976.746964
HOMEOWNER LICENSE EXEMPTION
New Pries
Dab
Job Location S oS� 5-/,e -
Home Owner Address 5 o s,. s �/ -, f
Home Owner Telephone s�8 - s - ,F 6
Present Mailing Address s
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
Persona) 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 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
f7
See other side for state code
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
VH; pit) ' Mlv I'II
N .�. p 11C �'.NIII\L:.w 5lMkrr •$.�11 11, S1.\�i.�� 111 �4 I••:1'r .
l'fL V1-74!6WJ5 •IC\!t:978-743-1946
Construction Debris Disposal Aliidavit
(required lur all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit Ill . _ is issued with the condition that the debris resulting from
this work shall he disposed of in properly licensed waste disposal facility as defined by MGL c
I It. S 150A.
The debris will be transported by:
(narna ol' 4-
hauler)
The debris will be disposed of in
(namea aci Ity
(address of t:uilily)
.ICI eofpernut.Ipphcans
S— 3 w
date