17 OSGOOD ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
�9 Revised filar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use O
Building Permit Number: Date Applied:
Building Official(Print Name) Signature ate
SECTION 1:SITE INFORMATION
L I perty�cJrcls G s , �� L2 Assessors Map& Parcel Numbers
I.la Is this an accepted street?yes__ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
zoning District Proposed Use Lot Area(sq ft) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Bear Yard Z.
Required Provided Required Provided Required Mided A
Cl)
1.6 Water Supply:(ivL(;.L c.4Q,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal Syst otn
zone: _ Outside Flood'Z.one? Zn
Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal Gotem 10
SECTION 2: PROPERTY OWNERSIIIP1 ur
2.1 erg of R cord: 7D
VC'JL QD
Name Print) City,State,LIP
J to i
No.and Street Telephone Entail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ rVteration(s) ❑ Addition ❑
Demolition Cl I Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify: _
Brief Descri tion cif Propos•d Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official U Only
Labor and Materials) Use n
y
I. Building $ I. 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 $ ?. Other Fees: $
4. Mechanical (I IVAC) $ List
5. Mechanical (Fire
Suppression) S 'Total All Fees: $
�
V heck No. Check Amount Cash Amount__
6. Total Project Cost. $ ❑ paid in Full ❑Outstanding Balance Due:
��2� l U
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL'I'ypc(see below)
No.and Street Type Description
U Unrestricted(Buildin s u to 35,000 cu. ft.)
R Restricted W FamilyDwellin-
Citvfrown,State,ZIP M Mason
RC Rootin Coverin
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(IIIC)
HIC Registration Number Expiration Date
I IIC Company Name or I IIC Registrant Name
No.and Street
Email address
City/Town,State,ZIP Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.§ 25C(6))
,Worker's 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 ABidavit Attached? Yes .......... ❑ No...........0
`7 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,its 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) Dale
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information
Ucontained in this a lication is true and accurate to the best of my knowledge and understanding. //,,
Prii hvner's or Authorized A gents Name Flectronie Si nature V /b' ( S ) 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 Flonte 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.ntass.eov/dns
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.) (including garage, finished basement/attics, decks or porch)
Cross living area(sq. f1J_ Habitable room count
Number of Fireplaces_____ Number of bedrooms _
Number of bathrooms _ - Numberofhalrbath.s
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open_
3. `"total Project Squire Footage"may be substituted for"Total Project Cost'
l: CITY OF Sc1LZE f3 LtiL1SS.ICHUsETTS
6L'1L0ING DEPARTMENT
120 WASHLNGTON STREET, 3'0 FLOOR
` Y TPL (978) 745-9595
KIMBERLEY MUSCOLL F.LY(978) TW-984d
LAYo:t
T1-[osLis Sr.PtE.gltt;
DIRECTOR OF PLBLIC pROPERTY/a LMLN CO.NL,, SSto,%ER
I
Construction Debris Disposal Aftldavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 QJR section 1 l 1.5
Debris, -utd the provisions of tA(GL c 40, S 54;
Building Permit hi is issued with the condition that the debris resulting from
(his work shall be disposed of in a properly licensed waste disposal facility as do Fined by 6gG c
I l 1, S 150A.
The debris will be transported by:
ti
'I � Sfc�P ('ter-►,r.�
(Home ut'hauler)
The debris will he disposed ot,in
o('lii-ilit/)
I
Grant
CITY OF SALEM, NIASSAC HUSETTS
BUILDING DEPARTMENT
N I! 120%VASHINGTON STREET 3RD FLOOR
q _= TEL. (978) 745-9595
FAX(978) 740-9846
KINLBERLEY DRISCOLL
MAYOR TY-IOMAS STRERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date ^^��
Job Location � � WCCON
cc Sr S°�I� M4— o15
c� JU
Home Owner Address &�
Present Mailing Address S r m 9�
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, an 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