18 OLIVER ST - BUILDING INSPECTION (2) T b S c,tc t S
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'rhe Commonwealth of Massachusetts q(
Board of Building Regulations and Standards CIyT{Y�,OAI SERVICES
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Massachusetts State Building Code, 780 CMR Revi eif!!'FAr � 0 ,q
Building Permit Application To Construct, Repair, Renovate Or Demolish a & SZ
One-or Tivo-Family Dwelling
This Section For Official Use Only
ISL DateA lied
Building Permit Number: :
PP
L_ Building Official(Print Nttme). Signature' Date
SECTION I:SITEINFORtLMAT10N
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
kD!-se!dUse
Lryex sfREEt dk Z
is an accepted street?yes ✓ no Map Number Parcel Number
ng Information: I.4 Property Dimensions:
strict -Proposed-Use - Lot Area(sq R) - Frontage(R)ingSetbacks(R)Front YardSide Ygnis - Rear Yard-ed Provided -Requhed - Provided. Required Provided
Supply:(M.G.L c.J0,§5d) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Private❑. Zone: _ Outside Flood Zone? Municipol O.Oo site disposalsystem O -.
Checkif, es0-
SECTIONS: PROPERTyOWNERSHIP!
2.1 Ownert of Record:
A �&Ex-scl 0ALCat' .i4A Ot9-4-a
time(print) - City,State,ZIP
srns-er 4 '+— 9�S 390 taati nn,¢ks�l, d a a; . CO AA
�, 4 l -
Telephone Email AJJ
No.and Street . P
SECTION 3: DESCRIPTION OF PROPOSED WORK](check all that apply)
New Construction 0 Existing Building O 'Owner-Occupied 0 Repairs(s) ❑ I A(terat(on(s) O Addition ❑
Demolition 13 Accessory Bldg.0 Number of Units_ Other 0 Specify:
Brief Description of Proposed Work=: Fv K t r cvaEH ¢E goo l 1•'` `«ctLiL-
G,�S r'� .v�1be..�tr t+E•tE wrEE.o E� 1 C.c be rr>:f� c�..,..cEQ_coP3 _ aPE.�
X CL. a �'c
' \ SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Itcui Labor and Materials -
1. Building $ SO a _ o a 1. Building Permit Fee:$ Indicate how ree is determined:
0 Standard Cilyfrown Application Fee
2. Electrical S 3 S'o - w 0 Total Project Cosh(item 6)x multiplier x
J. Plumbing $ 2 S� °• �° 2"A ptherFees: S
X q.M1lechanical (FIVAC) S List:
5. Mechanical (Fire S 'rota)All Fees:S
Su ression)
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S (05 C-5L�' ❑paid in Full ❑Outstanding Balance Due:
(Y)fall_ i 1/ r,-3w
hiAtL—GC) I 'Z,1
Upl*rl3' ..
`r. JAV ', a SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
e
License Number Expiration Date
Name of CSL Holder
List CSL'Type(see below)
Type. - - Description
No. and Street
U Unrestricted(Buildings no to 35,000 cu. 11.
R - Restricted 1&2 Family Dwelling
Cityfrown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
-Telephone Email;uldrcss D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
I IIC 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.M;. 2SC(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 Wuance of the building permit.
Signed Affidavit Attached? Yes..........O No...........O
SECTION 7a:OWNER AUTHORIZATION TO 8E COMPLETED.WHEN
OWNER'S AGENTOR CONTRACTORAPPLIESFOR BUILDING.PERMIT`
1,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
\' S.hMGS Mors - k i Ito Itte
/( Print Owner's Name(Electronic Signature) _ Date
\ SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION
By entering my name below,)hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
___Snot registered in the Home.lmprovement Contractor(HIC) Program);will 1MJ have access to the arbitration
program or guaranty fund under M.G.L.c. 1 J2A.Other Important iii o mation on the H►CTfogram can be fou�nl 3T --
www mass.gov:'oca Information on the Construction Supervisor License can be found at www.nuas�
2. When substantial work is planned,provide the information below:
'Total fluor area(sq. ft.) N ,(including garage, finished basementlattics,decks or porch)
Gross living area(sq. 11.) 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
3. "'Total Project Square Footage"may be substituted fur"rutal Project Cost"
a
CITY OF SALEM, MASSACMEM
BUILDING DEPARTMENT120 WASHNGTONSTREET,3RD FLOOR
TEL. (978)745-9595
F
KIMBERLEYDRISCOLL FAX(978)740-9846
MAYOR TY-TOMAS STAERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CON&SSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date I � 2of It.
Job Location lob 'Sr4zEs-- t4 'I- 5R e. A A otg4v
Home Owner Address 5A . '- As AG- V E
Present Mailing Address 5A V.e 6 s AB b.re
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
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 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 INSIDECT
CITY OF SALEA MASSACHLBEM
� BEnDngG D$PAR7mwr
120 WAStII 4MMSTRMET,3PRI.00R
AL.(978)745.9593
FAX(978)7449946
HIIvJBERLEYDRiSQ7LL
MAYOR 7)ICKU STAEM
DIRECTCRCFPUMUCFROnm1BuHIDWG jCgffi=
Construction Debris Disposa/Affidavit
(required for 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 coo S P 54; BuildingPermit g
is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be tr
ansported by:
S4n..<S .i,�Er',c1f (uwlyi�l c{i WL4� caa,..�.�clQ�- KaN�.EIL
(name of hauler) E)
The debris will be disposed of in:
N 02TN DCOE 'NLA(name of of facility)
$wAMPT COC'T (L7 S4L�CW\ '
(address of facility)
Signature of applicant
Date
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