7 OSBORNE ST - BUILDING INSPECTION sca The Commonwealth of Massachusetts
p' OF
Board of Building Regulations and Standards CITY S M
Massachusetts State Building Code, 780 CMR
ReviseddMar
Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official We Only
Building Permit Number: Date plied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: / 1.2 Assessors Map&Parcel Numbers
7 n5/So�n�c S / a7- 6>?fr11 --0
I.1 a Is this an accepted street?yes no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
�-5 11 . ///
Zoning DistrictProposed Use Lot Area(sq ft) Frontage(8)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.O.L a 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? �/
Public Private❑ Check if yes❑ Municipal k'� Dn site disposal system ❑
SECTION 2: PROPERTY OWNERSIHPt
2.1 Owner'of Record:
fdvtJ le lJouUA /lr✓TRA>�s :� sngs> • c>/92a
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) WotAlteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Work2: ,ST..i%J 4 aeeRooi�/Jsv- /for'' ��h .vim•--� 1?0�
S'4 �✓;L PS
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ ; 6W ._CX) 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ /-
4.Mechanical (ITVAC) $ List:
5.Mechanical (Fire Su $ Total All Fees: $
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
4
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
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.ft.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
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.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 AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,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 name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true ccurate to the best of my knowledge and understanding.
Pri wner'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
(not registered in the Home Improvement Contractor(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
www.mass.eov/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 basementlattics,decks or porch)
Gross living area(sq. ft.) Habitable room count 6
Number of fireplaces O Number of bedrooms y
Number of bathrooms ,A Number of half/baths p
Type of heating system 0.< Number of decks/porches cs
Type of cooling system r., Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
L
CITY OF S.U.&M. NLkSSACHUSETTS
BUILDING DEPARTMENT
130 WASHIINGTON STREET, 3�FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KIN
iBERLEY DRISCOLL
MAYOR THom&s ST.Pmms
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMSSIONER
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 c 40, 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 disposal facility as defined by MGL c
111, S 150A_
The debris will be transported by:
(name of haulerl
The debris will be disposed of in :
111 s2� Sire e'l-'r 7-v/
(name of facility)
(address of facility)
i
signature of permit a�licant
date
Je'bri. lJ d m
CITY OF S.UX.N1 '
PUBLIC PROPERTY
DEPARTMENT
o.su�u
VArae 175 iAoaPsGTtw 9MffW•SALuk%&.nAa&sam 011'e
to tees r,sssss•
HOMEOWNER LICENSE EXEMPTION
Please Mat
Date //-/F:/?
1obLoeation '7 o5i3oAcw 2. -S'T
Home Owner Addten 7 a s 166.2.v c 5 s st e� n c s
Home Owner Telephone i - 3
Preamt Mailing Address 7 os6a ,u-e � <ir� � s2�sr•
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units at leas and to allows such homeowners to engage an individual for
hire who does not possess a Heaneq provided that the owner acts as supervisor,
DEF24MON OF HOMEOWNER
Person(s)who owns a pared of land on which ha/she redden or intends to reside. on
which then Nat or is intended to be,a one or two flunily 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,
"fsomeownea"shall submit to the Building O[llci4 on a form acceptable to the Building
Offlcial. that he(she be responsible for all such wort 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 helshe understands the City of Salem
Building Department minimum inspection procedures and requirements and that helshe
will comply with said procedures and requirements.
HOMEOWNERS SIGNATL
APPROVAL OF SUILD17 INSPECTOR
See other side for state code