6 PATTON RD - BUILDING INSPECTION CASH
RE C
The Commonwealth of Massachusetts INSPECTIC NALffifWES'
Board of Building Regulations and Standards SALEM
I Massachusetts State Building Code, 780 CMR
2015 MAY I1tUPvsK,Sru'i
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This tion For Official Use Only
Sec
Building Permit Number: Date.A Iieds
Building Official(Print Name). Signature - Date
SECTION 1:SITE INFORNIATION'
1.1 Property Addrgks. 1.2 Assessors Alap&Parcel Numbers
(o ( kfun V-A
1.I a Is this an accepted st et?yes no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zuning District Proposed Use Lot Area(sq f1) Frontage III)
1.5 Building Setbacks(R)
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:
Zone: Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ — Check if es❑ P y
SECTION2: PROPERTY OWNERSRIPF 44
2.1_ 11a'ertof0L'a
\ 99 fine(Print) (ll City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction 0 Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Altemtion(s) ❑ Addition ❑
Demolition Cl Accessory Bldg.O Number of Units_ I Other ❑ Specify:
Brief Description of Prop osed Wark=:
CrV IZ ILDn AS Fnr�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Itcm Estimated Costs: Official Use Only
Labor and Materials)
I. Building $ I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Cown Application Fee
2. Electrical $ ❑Total Project Cosh(Item 6)x multiplier x
3. Plumbing S 2P Qiher Fees: S c_
4. %lechanical ([IVAC) S List (�L
5.Meehanicni (Fire S Total All Fees:S
Suppression)
Check No._Check Amount: Cash Amount:_
6. Total Project Cost: S 3 o d G d U ❑Paid in Full ❑Outstanding Balance Due:
M/N.tt_oD 5�z1
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL'fype(see below)
No. ,md Street Type- :.; : . Description
U Unrestricted(Buildings tip to 35,000 cu. 11.
R Restricted 1&2 Family Dwelling
City/town,State,ZIP M Masonry
RC Roofing Covering
WS 1Vindow and Sidin
SF Solid Fuel Doming Appliances
II Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
IIIC Cump;my Name or HIC Registrant Name
No.mid Street - Email address
City/Town,State ZIP Telephone
SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.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 Is§uance of the building permit.
Signed Affidavit Attached? Yes..........❑ No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE.COMPLETED.W HEN'
OWNER'S AGENT OR CONTRACTORAPPLIES FOR BUILDING PERMIT`
1,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Nance(Electronic Signature) Dale
SECTION 7b:OWNEW ORAUTHORIZED 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 k application is true and accurate to the best of my knowledge and understanding.mIA, C 6 ,e- l`efk S (i I �
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 not have access to the arbitration
program or guaranty fund under 1I.G.L.c. 1 d2A.Other important information on the HIC Program can be found at
w+vw mass eov;'oca Information on the Construction Supervisor License can be Found at www�ns .
2. When substantial work is planned,provide the information below:
"Total fluor area(sq. R.) `A .(including garage, finished basementlattics,decks or porch)
Gross living area(sq. 11.) Habitable room count
Number of fireplace, Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
'fypeofcoolingsystem Enclosed Open
3. "Total Project Square Foutage'may be substituted for"Total Project Cost"
QTY OF SALEM, MASSACHUSETTS
l� BUILDING DEPARTMENT
120 WASHINGTONSTREET,3"D FLOOR
TEL. (978)745-9595
FAX(978)740-9846
KINIBERLEY DRISCOLL
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMNIISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date ( r �r-( 5 1 n ( nn p
Job Location (9 Ft1J4•� 1�nn(A c5c,(Ci1 M A <00 70
Home Owner Address l0 pk� kk cu Sb(e k- 'lilt of iyo
Present Mailing Address '2 nti� �46 A (Lb- SG(eh /Y� Q- U K 10
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