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5 OSBORNE ST - BUILDING INSPECTION (4) Q� Tile Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF �j Nfassachuselts State Building Code, 730 CMR SALEM Revised A(lar r7r 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Tivo-Family Dwelling [his SectionFbrOff ' se Oril Building Permit Number. . ta,Applitd: 1g: Budding OfficiaL(Print Win a) signature. Data SECTION 1:SITE7NFORAIATION 1.1 Pro arty Address: 1.2 Assessors Map& Parcel Numbers Osbor✓C L la Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning[nformatlon: 1.4 Property Dimensions: Zoning District Proposed Use Lot Ares(sq R) Frontage(f 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Requited Provided Required Provided ' 1.6 Water Supply:(M.d.L c.40,§54) 1.1 Flood Zone Informadoas LS Sewage Disposal Systems Public M/ Private❑' Zone: _ Outside Flood Zane? Municipal al CrOn site disposal s stem ❑ Check if e$G4 P Y gOrTrnNl1 P[tOPERTII'0�9(VERSFID 2.1 O nerrof ord: gmailAddress 2� nt) s6IPo Ma Name(Print) City,Stazq ZIP � r(vr Ct, No.and Street ^Telep on / SECTION J: DESCRIPTION OF PROPOSED WORW'(cbeck all that apply) New Construction ❑ I Existing Building Owner-Occupied 91 Repairs(s) 4lteration(s) ❑ Addition ❑ Demolition Accessory Bldg. ❑ Number of Units 1 Other ❑ Speeity: Brief Description of Proposed%Vork t C S SECTION 4: ESTIILITE!]CONSTRUCTION COSTS' stem Estimated Costs. O. 1 . Use Only.. Labor and Materials y' .. I. Building S .t!D 1. 8uilding Permit Fee:4 Indicate haw fee is determined: r. Flectrica S I?Sland.4 Cityff %vnApplication Fee, ` ❑'Cotal Project Cost(Item 6)s multipliar x 1. Plumbing i ?- Gther Foes .S List: i. \lech.mic.il (Piro . I'oni All Fees: S -- --- ChaclPlo. Chcc$,lmount: (',ish :\uiounc _ I U P,lid ill 1'1111 , Cl thd;L111dim� lhi:utco I )1w _ _ w SrcrION 5: C(1NSTRUCI'ION SERVICES 5.1 Construction Supervisor License(CSL) l.itense Number Expiration Dnta N,IIme of CSL I folder List CSL rype(see below) Typo Description No. mid Street U Unrestricted Duildln s u to 35,000 cu. I It Restricted M!i-Millix Dwelling City/rovvn,State,ZIP IN, Masonr RC Ruulin Cuvcrin W5 1Vinduw nnJ Sidin SF Solid Fuel tluming Appliances ( Insulation ' 1'a!e hung Email address D Demolition 5.2 Registered Hone Improvement Contractor(H(C) ► FIIC Registration Number Expiration Date I IIC Company Nama ur 11IC Registrant Name Email address No.and Street City/Town, State ZIP Tale have SECTION 6: WORKERS'CObIPENSA'TION 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.......... ❑ SECTION 7a: OWNER AUTHORIZATION TO DE COhIPLETED WHEN OWNER'9 AGENT OR CO�TIL►CTOR APPLIES FOR HUILDING PERMIT (, ns Owner of the subject property,hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Data Print Owner's Name(Eieetrante Signature) i SECTION 7h: UWNERt OR AUTILOA(ZED:\GEN'T DECLARATION By entering my name below, ( hereby at st under the pains and penalties of perjury that all of the information true a ceurate to the bast of my knowledge and understanding. cuntai 'n this alurucLrAgelit'i'MI111 licati n /� Oate Print wnei s ur.\u �(Glectrunie Signature) NOTES: I. :\n Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered cuntnctur (nut registered in the Home Improvement Contractor(H(C) Program), will no have access to the arbitration program or guaranty timd under NI.G.L. c. 142A. Other important information on the H(C Program can be found at w,NY III'It �.:ov%ore (ntormation un the Cunstruction Supervisor Lircnsa ern be found at uww.mass.,�v_,lu 2. 1Vhen substantial work is pLmned,provide the information below: lour area ;, . It.) _(including garage, tinislied basement/attics,decks or porch) total t ( I ----- F[ibitable room count _ iro;; living:uc:t(';,Ltt.l -- Number ofbcdrulnns mimberoflirepl.Icci ,_-- _.....__-- ------- - ——.--_-- Nlunber„fhalEbmhs --- '-- \'iunbcrof�lcc\,•,' I'„rilte; — --- I•.I,uofh;.uiu,; ;y;I�"' -- - Pncll Ilpen �. t ..I•,t II I'ny.•,.t ;.III ua I �,,,t he alh duw:,l t,a I •Lil Iraq,:.l ( ,�-t- __ r. CITY OF S.VLENI lip PUBLIC PROPERTY DEPARTMENT W uAY/Y rt.r•.w� _. VArae 1 b WUMPWTq,Rfaar•ULAK.VASAow sera et 9-0 to+'tru.ostt•PA&rar,a Asa. HOtA EOWNER LICLNSB E.1(E.%ffj0V Peew "I Date L } lob Loc&dm S 0 5 Un(n.) e u` I s Home Owner Address Home Owner Telephone - PresentMailiagAddtrees Sa,mr The current exemption of"Homeownue"was extended to include owrnar-occupied dwellings 0(two Units or lean and to SHOW such homeowners to eagsgr an individual for hire who does not possese a ticons4 provided that the owner acts as supervisor. DEMMON O/HOMEOWNER Person(#) who owns a pared of land on which bloke resider or Intends to reWde6 on which then U6 or is intended to b46 a one or two /amity dwelling, attached or detached structures accessory to such use and/or rum a clu ees. A person who connstmcts more than one homs in a two year period shall not bt considered a homeowner. Such "homeowner"shall submit to the Building OQieial,on a form acceptable to the Building Official, that hdshe be responsible rot all such worst performed under the Building Permit The undersigned "hameownd'asaurnes responsibility for compliance with the Stair Building Code and other applicable by-laws and regulation& no undersigned "homeowner certifies that hdshe understands the City of Salem Building DepaMent minimum inspection procedutes and requirements and that he/she •vill comply with said procedures equirem ts. HO MEOIA NERS S[GNA TLRB .kPPROVAL OF eWLONG O;SPECTOR S<e other side far state code d I 1.1 l C V 1 JC IL..Gy`t , • � I, ,bL,55,1CHL'SETI'S i + ( Qt'tLDLYC DEP.IR73lE.vT I o Vv,Ijx LVGTON sTIiE$T 1 FY.00R °'~ ILL (973) M-9595 IMORRE Y ORISCOLL FI-X(979) 7•IU-9344 AMA -l1l000ST.P1Ejm i DI:u3CTOa OF PLOUC PR0PEQ7Y/SCILOLYG CO3L1!!S5lO,V&R Construction Debris DispOsai Aft7davit (required for all dcmalitiun and runuvation work) In accordance with the sixth edition of the State Building Cade, 730 C+bIR section l I LS Debris, and the provisions of MOL c 40, S Sd; ©wilding Permit 4 this worlc shall be is issued with the condition that the debris resulting from t 11. s l Jn,�. disposed of in a properly licensed waste disposal Facility as defined by ,LIGL o Tho debris will be tru,sportcd by; �IL7e/S� f Iti, Monu/��f) (name ut nautur) The hubris will bo disposed of in ; (nan,u of t�udit�) AI_Q F ( Llress ui ri,,iln�) iquamru of Pcrnn I . }.plianit