0 BAKER'S ISLAND PARC. # 46-0073 - BPA fhe Commonwealth of Massachusetts —
h Board of Building Regulations and Standards CITY OF
�V sj,t Massachusetts State Building Cade, 780 CMR SALEN.I
L„W Revised.Vur 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Fumily Dwelling
This Section For 011icial U e Onl
Building Permit Number: Date Ap ied:
Building Oliicial(Print Natne) Signature Date
SECTION 1: SITE INFORNIATION
1.1 Property Address: 1.2 Assessors Map& Par Numbers
4ree ��(r-ao73 d
I.I a Is this an accepted street?yes_ no Map Number I'arce Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yams Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.GJ.c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private F_�'/ Zone: _ Outside Flood ZoJle?
Check ifyus0' Municipal ❑ On site disposal s')stem 9/
SECTION2: PROPERTY OWNERSHIP'
2.1 wnert of Record:
�2 ,r '44 N� c 6I o d /4 /�4 0o23�
Nm1e(Print) ' City.State,ZIP
3 C45<1 etrzLr -953�
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) ❑ 1 Alteration(s) Addition ❑
Demolition ❑ 1 Accessory Bldg. Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
1A4 /aJ lam.
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials) Official Use Only
I. Building S 0 D i 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IfVAC•) S List:
5 Mechanical (Fire S _
SLlyressionl Total All Fees: S
Check No, Check Amount: _Cash Amount:______
6. Total Project Cost: S ❑ Paid in Full ❑Outstanding Bal:mce Due:
�� 7
SECTION 5: CONS-rRUCTION SERVICES
5.1 Construction Supervisor t.icense(C'SL)
License Number lixpiralion Date
Name of CSI- I lulder
List CSI-1)pe(sec betow)
No. and Street ---- 'type Description
it Ilnreslricted(Buildings Up to 35,000 cu. 11.)
R Restricted 1&2 Family Dwelling
Ciq.l1'mm,State,ZIP M Masonr
RC Rooling Covering
- - W S Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Iintail address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC'Registration Number Expiration Date
I IIC'Company Name or I IIC Registrant N;unc
No.and Street
Email address
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 .......... O 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 authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and enalttes of perjury that all of the information
contained in this�appl' i is ue and accurate to the b of my knowledge and understanding.
Print Ottners or Authored Agent's Muse(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do hisiher 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%I.G.L.c. 142A.Other important information on the HIC Program can be found at
hc:J Information on the Construction Supervisor License can be found at���y�q.in_i >.gu�.'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. 11.) Habitable room count _
Number of fireplaces Nmnber of bedrooms
Number of bathrooms Number ofhalfbaths ---- — - —
---------------- --------------------
Ty pe of heating system--_---------------_-- Number of decks, porches_-_
f)pcofcooling Sy Stem_ _ _ _ Enclosed -- ---- Open _------- ---- _
1, "focal Project Square Footage"may be substituted fitt"focal Project Cost"
CITY OF S.VL&Ni, AASSACHUSETTS
i
3LMDNG DEP.1RTt NT
120 1W-ksHLNGTON STRMT, Y°FLOOR
I-EL (978) 745-9595
FAX(978) 740.9W
KINMERUY DROLL
MAYOR D iCIMU ST-PIER"
DIRECTOR OP PLBLIC PROPERTY/aLMDLVG CON
L%((SS(ONER
Construction Debris Disposal Affldavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section l l 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit k 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
I 11, S 150A.
The debris will be transported by:
1) 0 v(j �7" 647,- ^ 2ik/�y
(name of haulm)
The debris will be disposed of in
S , "lo.ra�cy) M
(name
S A em n�lk S
(address of facility)
'11"fure of permit applicant
9- 7-/i
date
S M1n ud.LM1
CITY OF &XI.E.M
PUBLIC PROPERTY
DEPARTMENT
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HOMEOWNER LICENSB EXEMPTION
Plesw Frlet
lob Location A-K err ESL A�
Home Owner Address c 4.fie e(rrL, , ,Nv L-6 n)0/L
Home Owner Telephone G / 7- --2//—9/(2
Present Mailing Address S A,M e-
The current exemption of"Homeowners"was extended to include ownar-occupied
dwellings of two Units Of fens and to allow sub homeowners to engage an individual for
hire who does not possess a lieesss6 provided that the owner sets as npwWsot
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to resider on
which then ia, or is intended to be,a one or two family dwelling, attached or detached
stnuattrres 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
Ofllcia4 that he/she 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
"ill comply with said procedures and eq irements.
HOME0WYER$ S[GNATL'RE
t --
APPROVAL OF BUILDING DiSPECTOR
See other side far state code