16 OSBORNE HILL DR - BUILDING INSPECTION 1 I q _ Z RECEIVED ICES
'rhe Conunomvealth of Massachus ITY OF
Board of Building Regulations and Standards A AALEM
Massachusetts State Building Code, 780 Cp Q�T _lo Revised,ilar2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Offici se Only .,
Building Permit Number. Date Appliedr
_Building 011icial(Print Name). Signature- - Date
SECTION 1:SITE INFORtNtATION'
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
16 psrsozrtc F I tl LL
L I a Is this an accepted street?yes t/ no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq tl) Frontage(11)
1.5 Building Setbacks(it)
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:
Zone: _ Outside Flood Zone? Municipal Cl On site disposal system ❑
Public❑ Private❑ Check if es❑ P
SECTION2. PROPERTY OWNERSHIP!:
2.1 Ownert of Record:
}Y A AOc c^j/�LE 1vlO (7I�I 1v
erne(Print) City,State,ZIP
lb 0DSG0i7_1gC f(IL` DRIVC Qlr
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction Cl E$isting Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work':
X lrrIslyIrPc vP THC TlI S9 c.c
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building S 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard Cityrrown Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2?Other Fees: S
4. Mechanical (IIVAC) S List: �� n
i, Mechanical (Fire S Total All Fees:S
Su cession)
�-1 Check Na._Check Amount: Cash Amount:_
X G.Tutal Prnject Cost: S '—)01XD [3Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
t t j License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type - - Description
U Unrestricted(Buildings up to 35,000 cu. It.
R Restricted 1&2 Family Dwelling
Cilyfrown,State,ZIP M Nlasonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Bunning Appliances
I Insulation
Telephone Email address D Uemolilion
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.IL 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 ..........❑ No...........❑
SECTION 7a:OWNER AUTHORIZATION..TO BE COMPLETED WHEN:
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERNIIT`
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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,)hereby attest under the pains and penalties of perjury that all of the information
�nta'fed in tht nppl'cation is true and accurate to the best of my knowledge and understanding.
_ 1 i0 6I1 Li
Print( wner's 6rAuthorized Agent's Name(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 nol have access to the arbitration
program or guaranty fund under�b1.G.L.c. I42A.Other important information on the HIC Program can be found at
www.muss.gov:'oca Information on the Construction Supervisor License can be found at www.mass.cov�ldys
2. When substantial work is planned,provide the information below:
Total fluor 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 heating system Number of decks/porches
Type of cooling system Enclosed Open_
3. ` total Project Square Footage'may be substituted far"Total Project Cost'
y
CITY OF SALEM, 1IMASSAalUSETTS
BUILDING DEPARIMENT
120 WASI-IINGTON STREET,31D FLOOR
� yxax� TEL. (978) 745-9595
FAX(978) 740-9846
KINMERLEY DRISCOLL
MAYOR Tmmm STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMNUSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date I C)11 t
lob Location 16 Osr;�,o'ZrcE F1( L` 1J2i vC- M✓t Oi l c�
Home Owner Address t9 r ?C
Present Mailing Address sr3r�c_
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 requireme is and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR
E � QTY OF SALEM, MASSAMUSEM
4 , TAiF BUILDING DEPARTMENT
s 120WASffiNGTON STREET,31DFLOOR
TEL.(978)745-9595
KIMBERLEYDRISOCLL FAX(978)740-9846
MAYOR THoMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CC)NMUSSIONER
Construction Debris Disposal 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 c40, S 54; Building Permit# 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 transported by:
T� I�
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
—T Date