39 OSGOOD ST - BUILDING INSPECTION (3) The Commonwealth of Massachusetts
Board of f MassachusBeuilding Regulations and tts State Building Code,7��ag5CITYOF
1C0��° SERVIC 5 S EM
evised Mar 2011
Building Permit Application To Construct,Repair, Renovate Or DegotFh
One-or Two-Family Dwelling . 19�5 PL
60 This Section For Official Use Only
Building Permit Number: Date Applied:
7 /a/lam
U ' Building Official(Print Name) Signature Date
-- SECTION 1: SITE INFORMATION
I 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1.1a Is this an accepted street?yes_LZ no Map Number - Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
19W10
Zoning District Proposed Use Lot Area(sq f) Frontage(f)
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? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
vvN -N7 Via SQ 4Q�-. YY\YQ Jl cii
Name(Pri t) City,State,ZIP
g1H3o�inJtreteds Telephone
L Srr'.ckhrd�resrsnsr..c
SECTION 3:DESCRIPTION OF PROPOSED WOW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Erl Repairs(s) Vr I Alteration(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work 2: Roi� of
W 4]ct SYl.v�a�e g �C- 5'v AX ..c o{ 11QObLFI \ngz v ant 4
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ ��. Cp I. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical g ❑ Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List: CIF )L
5.Mechanical (Fire $ Total All Fees: $
Su ression
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑ Outstanding Balance Due:
MQiX, -1 � to
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
i`
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildin2 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
Improvem!e�nt Contractor(HIC) l5�%.) 3 3!A 16
%qC
Q \C3c HIC Registration Number Expiration Date
ompany ame or HIRegistrant Name Apa y 6� PQ� c\c 4\o��n® Sn C�_ v"No.and Street mail address
Se1¢N. vv\A tR10 g18lyta_ o1o3
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
I,as Owner of the subject property,hereby authoriz�?o-k Lk �oa2n _
to act on my behalf, in all matters relative to work authorized by this building permit application.
5- 1-
Print Own N.I c(Electronic Si e) Date
SECTION 7b: OWNERS 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 and accurate to the best of my knowledge and understanding.
i- / '
Print Owne uthorizcd Agent's N (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. og v/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"
CITY OF S.U.&M. TANSSACHUSETTS
• Bl MDLNG DEPjLR-nm%'T
• 130 W ASHNGTON STREET, YD FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KIN FY DRISCOLL
1Ll,+►YOR T�todtAs ST.PtERRE
DIRECTOR OF PUBLIC PROPERTY/Bun.DING CMDUSSIONER
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 a hauler)
The debris will be disposed of in :
(name\of
facility) 1 —
SWGrv��SC��T 2c� Sn�eM
(address of facility)
si to f permit applicanO
date
dcbri,afrAx
aCITY OF SALEM, MASSACHUSE TTSBUILDINGDEPARTMEMHI 120 WASNGTON STREET,3"DFLOOR
TEL. (978)745-9595
F
KIMBERLEY DRISCOLI. FAX(978)740-9846
MAYOR THomAS ST.PIERRE
DIRECTOR OFPUBLICPROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date
Job Location 3 ? OS G av Q .ec
Home Owner Address 3 `l e-jj .s65-r�
Present Mailing Address 3 9 USA oou� ,S 7
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