47 OSGOOD ST - BUILDING INSPECTION 1
— ----- e Co nunom veatlth of Massac
Th husetts
((� 1,, Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 730 CNIR SALL,%I
Building Permit Application To Construct, Repair, Renovate Or Demolish a
tble-ur Tor,-Fumilr Dn ellm,\r
'this Section For Official Use Only
Building Permit Number: Date 1p ied:
—Lding �'Lif�,�5
Building Official(Print Name) Si lure pule I
SECTION I:SITE INFO IATION
I.I Property Address: SA 6i9fG� 1.2 Assessorsklap& Parcel Numbers
I.la Is this an accepted street?yes ✓no Map Number Purcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Uso Lot Area IN R) Fmninge(It)
1.5 Building Setbacks(R)
Front Yard Side Yards
Rear Yard
Reyuircd Provided Reyuircd Provided Reyuircd Provided
1.6 Water Supply:(M.G.1.c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check fifes❑ Municipal❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
Zr� 2.1 Ownerl of Record:
5y4 ) c& m
,
N;une(Pnnq t uy.Slate,ZIP ,
c
Nu'n° greet I cle hone
P Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Spwil'y:
Brief Description of Proposed Work': i2 r•it v N�.y i
SECTION 4: ESTLMATED CONSTRUCTION COSTS
Itcm Eslii aced Costs:
(Labor and ..\laterials) Official Use Only
I. Building g I. Building Permit Fee: S Indicate how fee is determined:
'. Electrical g ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier .x
?. I lurching 5 2. Other Fees: S ---- ------
i \Icchancai IIl1:\C'1 5 List: �0-�
?. \Icchunieal Wire _ __
116���
Su„ressionI S 'rotal :\II Fees: S_ --__ ------ -------. .
I,. Total Project Cost: S C'hcek No. __('heck :\mount: - ------_C'ash \mount: ..
C ! C 0 Paid in Full 13 Outstanding Balance Due:
f 1
SECTION 5: ('ONS"I-RUCTION SERVICES
5.1 Construction Super isor License(CSL)
License Naha r I \piration Dale
N:une ol'C SI. I lulder �—
List CSI.1')pc Isee bclu\vl
-p\pe Description
No, and Street �------------
1 l Inrestricted I Ihlildin 1!s UP to 35,0110 cu. It
R Restricted 1&,21:anvil ' D%wilina
Citci toll n,Slutc.LlP NI Mason
RC Roo in C'uverin
._ W'5 A induw and Sidol
SF Solid Puel nurning Appliances
Insulation
I cle hone Ifniail address D Denlolilian
5.2 Registered home Improvement Contractor(HIC)
IIIC Registration Number Expiration Date
IIIC Company N;une or IIIC Registrant Nunn
No. mid Street Emuil address
City/Town,State,ZIP Telc hone
SECTION 6:WORKERS'COMPENSATION 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 .......... ❑ No........... ❑
SECTION 7s: 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 O\vner's Name(Electronic Signature) Date
SECTION 7b: OWNERI OR AUTHORIZED AGENT DECLARATION
By entering my name below,1 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.
etia✓a yL Cosj��a l; s-�I
Print D\\ner's or Authorircd Agcnl's Naoic(T'lectrunic Signature) Da1e�
NOTES:
I. An Owner who obtains a building permit to do his.her own work,or an owner who hires an unregistered contractor
(nut registered in the Hume Improvement Contractor(HIC) Program),will no have access to the arbitration
M.G.L.c. 1 J_'A. Other important information on the HIC Program can be found at
program or guaranty land under p
\\\\\\ m.r.. .,O\ 01.I Information on the Construction Supervisor License can be found at Fyn Ip,
2 When substantial work is planned, provide the information below:
Total flour area(sq. ft.) _ _--_(including garage, linished basement'anics,decks or porch)
Gross living area I sq. 11.) _- " Habitable room count
Number of fireplaces--, Mother ufbedruunis
Number of'bathrooms — — _- " _-_— Number of lialf h;ilis -
I\pe of heating s)stem Number of'decks, porches .. _.
I\Ile,if en\i 1111g i\\le lit - - Fncloicd _ _ " - Opelt
i1 ''I'i�1u1 I'nijcct Syuure Poatnge"ma) he SIIb5tltntcd fir, I'olal Project Oust"
CITY OF S,ULENI`j Ausikaf usETTS
at:MDCYG OumtT\t&iT
- 120 W.ISHLNGTON STU". J'FLOOR
PEL (978) 745-9595
KIJ®EM -EY DRLSCOLL FAX(978) 740.9946
MAYOR THO.�Ls1 S7.PiEtttit;
DtRELTOR OP PCBLIC P1tOPERTY/aL:MDLYG CO\p11SSIONER
Construction Debris Disposal A117davit
(required for all demolition and renovation work)
In accordance with the sixth edition orthe State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL a 40, S 54;
Building permit M this work shall be is issued with the condition that the debris resulting from
11 1, S 1 SOA. disposed of in a properly licensed waste disposal facility as defined by HIGL c
The debris will be transported by:
j r
_/'2� �/', ( ne �%L' Il T` l�,P f_'_./SG%I t.l 'i✓ ✓ j`/
(Dame of hauler)
The debris will be disposed of in
OddrClj of rj,:11, y)
114"rure ofpermlt Jppllcmt
r:Jfe
CITY OF S.U.E.Ni
PUBLIC PROPERTY
DEPARTMENT
waWat oasu�u
vnroa i b�► sneer�suaa�woeoasicns ot1,'0
M 9:6-745.9s+s•F.u.978-740.7646
HOMEOWNER LICENSE EXE.MMON
Piers "I
Date
Job Location `/ 7 c ci ;5 si r4 /.�� , i�� 0 9 7
Home Owner Addreae
Home Owner Telephone 9> 2 =
Ptesmt Mailing Address
The current elempdon of"Homeowners"was extended to include ownw-occupied
dwellings of two Units at less and to glow such homeowners to engage an individual for
hire who.does not possess a licensed provided that the owner acts as supervisor.
DEFINM0N OF H0hM0WNMt
Persons)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 dweWmg, attached or detached
structures accessary 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
mill comply with said procedures and
requirements, 1
HOMEOWNERS SIGNATL REj� -> / �•�.,,, iiT //��`L�L�c ,,�'
APPROVAL OF BUILDING NSPECTOR
See other side for state code