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10 OUTLOOK HL - BUILDING INSPECTION �0 / Q The Commonwealth of Massachusetts Town of 1h Board of Building Regulations and Standards 7� Massachusetts State Building Code, 780 CMR, T"edition immomw Building Dept ` Building Permit Application To Construct, Repair, Renovate Or Demolish a One. or Tno-Fanlilv Duelling This Section For Official Use Only Building Permit Num r: Date Applied: Signature: 961) oi-I Bud ng Commissioner/ n of Buildings Date SECTION 1: SITE INFORMATION I.I Pr erty Address: 1.2 Assessors Map d Parcel Numbers O r Ma Number Parcel Number 1.la Is this an accepted street'?yes_ no D 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq B) Frontage(B) 1.5 Building Setbacks(ft) Front Yard Provided Yards Rear Yard Required Provided Required Provided Required I Provided 1.6 Water Supply:(M.G.I.c.40.154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Public❑ Private❑ Check if vcsE3 SECTION 2: PROPERTY - WNERSHIP' 2.1 wnert of Reco it7 © tlf O e l Na int) ^ ,- _ Addre)s for Service: L d � ,mow. cn.Afl / Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply) New Construction ❑ Existing Building airs(s) P- Alteration(s) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ I Other Cl Specify: Brief Description of Proposed Work': I1 zt SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item Labor and Materials I. Building f I. Building Permit Fee: f Indicate how fee is determined: O Standard City/Town Application Fee 2 Electrical S ❑Total Project Cost'(Item 6)x multiplier x 3 Plumbing S 2. Other Fees: f 4. Mechanical IHVAC) S List: t Mechanicat (Fire S Total All Fees: f Su ressron Check No. _Check Amount: Cash Amount:_ 6. Total Project Cost: S ❑ Paid in Full O Outstanding Balance Due: t1lo �y Z� SECTIONS: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) Lwerae Number E%pumion Date N4me ul'CSL- Helder k iLut CSL Type(see below) Address T'pe Description U Unrestricted(up to 55.000 Cu. Ft.) Signature R Restricted 1&2 Family Dwellm M I Mason Only RC Rcstdcnnal RoofingCovering Telephone W'S Residential Window and Sidra SF I Residential Solid Fuel Burning Appliance Installation D I Residential Demolition S.2 Registered Home Improvement Contractor(HIC) HIC Company Name or HIC Registrant Name Registration Number Address Expiration Date Signature Telephone 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........... 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 1• , as Owner r Authorized Agent hereby declare that the statements and information on the foregoing application are true rate,to the best of my knowledge and behalf. t- Printtum o gnaf Owner or Authorized Agent Date Si red under the pains and penalties of per 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 HW have access to the arbitration program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS, respectively. 2. When substantial work is planned,provide the information below Total Doors 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 ofcooling system Enclosed Open I. "Total Prolecl Square Footage" may he auhslitutcd for 'Total Project Cost" CITY OF SAI_E.%vt PUBLIC PROPERTY DEPARTMENT ufakJlill n...r.ti. 1ewv0� 130 WASUNGMN STUNT•SLLEK VA1MA06LSEM 011'0 TF197L7J1739!� PAi.9'N�67aN r` a HOMEOWNER LICENSE EXEMPTION Plan"Print Dam o Job Location ✓� I� 0,)4-( .k ALI I Home Owner Addtsas )-He)nle till Home Owner Telephoned Present Mailing Address f o ©u+(n e K The current exemption of"Homeowners"was extended to include owner-occupied dwellings of two Units or lea and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFENMON 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 dwellin& 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 OQicia%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 will comply with said procedures and requirements. HOMEOWNERS SIGNATURE �(—c - Lc APPROVAL OF BUILWNG INSPECTOR See other side for state code