25 OSBORNE HILL DR - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 C RECEIVE SALEM
SPECTIONAL S'RM1QE$lar2011
Building Permit Application To Construct, Repair,Renovate Or Demolish a
One-or Two-Family Dwelling talkM!n "
This Section For Official Use Only
Building Permit Number: Dal Applied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
].1 Property Address: 1.2 Assessors Map&Parcel Numbers
Z !1411
1.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: Ad 1.4 Property Dimensions:
11QS�tkm t°_
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Private❑ Zone: _ Outside Flood Zone?
Check if yes Municipal•% On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Dcsytst MGtl4h Saileet M 0/176
Name(Print) City,State,ZIP -
;tS 056,wv- HAI at;- 4178-157t-6167 eQ�mac�ty @�htai/. or,
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WOW(check all that apply)
New Construction❑ Existing Building 0 Owner-Occupied X I Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
BriefDeel riptionof Proposed Work: Illsulotfiov,a
AO�JvcDc /SXl7 ' 1 .+ SJ2
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 3f YDO p p 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ g Sir , Ov ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ Npt] 2. Other Fees: $
4.Mechanical (HVAC) $ r UJJ , of List:
5.Mechanical (Fire $
Su ression NI 4 Total All Fees:$
DM Check No._Check Amount: Cash Amount:
6.Total Project Cost: $ �- O ❑paid in Full ❑Outstanding Balance Due:
MfM S4' <r IYT57 At
Ak t- -Q cl ( t z-
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
i.. License Number Expiration Date
Name of CSL Holder !A�,�„
List CSL Type(see below)
No.and Street' {` ?., �j't R� "S Type Description
V Y
U Unrestricted Buildin s u to 35,000 cu.ft.
City/Town,State,ZIP
R Restricted ]&2 FamilyDwellin
M Maso
RC Roofin Coverin
WS Window and Sidin
SF Solid Fuel Bunting Appliances
I Insulation
Tele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
i
No.and Street
Email address
Ci /Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.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 AUTRORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,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 Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my belo hereby attest under the pains and penalties of perjury that all of the information
contained in icati s true and accurate to the best of my knowledge and understanding.
t sap
khVIPrint Owner's or Authorized Agent's Name(Ele onic Si lure) DFateI
1. An Owner who obtains a building permit do his er own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Co or(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
w-ww.mass.¢oy/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor 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 for"Total Project Cost"
I
1
CITY OF SALEM MASSACHUSETTS
rh
4 BUILDING DEPARTMENT
120 WASERNGTON STREET,3m FLOOR
��nvur TEL. (978) 745-9595
KIMBERLEY DRISCOLL FAX(978)740-9846
MAYOR THomAs STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMVUSSIONER
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:
-potti Y 1 t4a4 f4
(name of hauler)
The debris will be disposed of in:
N U✓i'h t7i tt
(name of facility)
5wu Mase,,f : f2J
(address of facility)
Signature of plicant
�1;&/ L/
Date
A
CITY OF SALEM, MASSAC IUSETTS
. !� BUILDING DEPARTMENT
> I ✓h`' 120%VASHINGTONSTREET,YD FLOOR
'ILL. (978) 745-9595
FAX(978) 740-9846
KINMERLEY DRISCOLL
MAYOR THomAS STTIERRE
DIRECTOR OF PUBLIC PROPE RTY/BUILDING CONIIVIISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date jrj7%r1/N
Job Location 2.S 05 6v,^t ^,,f 0117f.
Home Owner Address 73- orla,,.^c * /1 DA-e- S, (U,1 + /✓;-* 01976
Present Mailing Address Zr oikcwyc H/ lf Dyne_ Sci(G.^-+ ' ~ 01470
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 INSPECTOR