18 OSBORNE ST - BUILDING INSPECTION 7-0
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
!`y j Massachusetts State Building Code, 780 CMR, T"edition OF SALEM
"'wwwy� Rrvrsrrl Junrnrry
uilding Permit Application To Construct, Repair, Renovate Or Demolish a /• =t//�Y
One-or Two-Fomily Dwelling
This Section For Official Use Only
Building Permit tuber:: - Date Applied:
Signature: ?' % 'i �U, /- / b
Building CommissionotPrnspector of Buildings Nate
SECTION 1:SITE INFORMATION
1.1 PProp�ert�y__Address: 1.2 Assessors Map At Parcel Number
I.la Is this an accepted street?yes Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(R)
1.3 Building Setbacks(R)
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? Municipal❑ On site disposal system ❑
Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
�S C 07T PALL.ET I Ell Q-Se0kAJE �S 1
Name(Print) Address for Service:
Signatu Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other dspecify:VI NyL c 7. I J I M&
Brief Description of Proposed Work': T�,,
L0GE 1 k) Do— c r
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town 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:
S. Mechanical (Fire S
Suppression) Total All Fees:S
`F, Check No. Check Amount: Cash Amount:
6. Total Project Cost: v ❑Paid in Full O Outstanding Balance Due:
�7 , 00
s
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervlsor(CSL)
License Number Expiration Dale
Name of CSI.-I lolder List CSL Type(see below)
T-Pe Description
Address U tlnrestricled(up to 35,000 Cu.Ft.
WRCR
Restricted It2 Famil DwellinSignature M OnlResidential Roulin Coverinfdephsne Residential Window and SidinResidential Solid Fuel Burning Appliance Installation
Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
f IIC Company Name or IIIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 Issuance of the building permit.
Signed Affidavit Attached? Yes ..........O No...........O
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.
Signature of Owner Date
-- /SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
y/
I, D / L L L E T K Ie ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
S C U 7r PtEL-L-f-�'-i E2
Print Name
SignatureofOwner or Aut 6rized Agent Date
(Signed under the pains and penalties of 'u
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 WJ have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I WAS,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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
J. 'Total Project Square Footage-may be substituted for"Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
r.IG MIr• .11. . 11 I-c 4'.NIMV..•w)l etrr j.\I1 N, fit.\•N\III 1.•.1'r -
Irl:v:/-:JS•ly/! �1°\:(:'/fl•NyreM
Construction Debris Disposal A111davit
(inquired fur:dl demolition artd renovation work)
In accordunt:e with the edition of the slate Building Code, 730 CMR section I
Debris. and the Provisions of MGL a A0,s u
,ss
is isrued with the condition that the debris resulting film
Building Permit N ( licensed Wore disposal facility as defined by MGL o
this work shall he disposed of in a proper Y
I 11. S 1311A.
The debris will be transported,by:
.- ' CI T�� C I_L1 '
ru nv�l
I lame of hauler)
The debris will be disposed of in
Qlame ul xl 1%
I:Iddrefe ul lx duyl
7
•./nature of Iwrmit apyli�aM
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CITY OF S.XI.E.Nf
PUBLIC PROPERTY
DEPARTMENT
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HOMEOWNER LICENSE EXEIMWION
Pk " "I
Date DTI 1 D
Job Locatim 19
Home Owner Address
Home Owner Telephone 7 — 4 —
Present Mailing Address 1=
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
hue who.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/sbe 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 hdshe 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 he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWYERS SIGYATLRE z
.APPROVAL OF BUILDING INSPECTOR
See other side for state code