9 PATTON RD - BUILDING INSPECTION (2) 0-
J �
The Commonwealth of Massachusetts
a OF
Board of Building Regulations and Standards CITY Massachusetts State Building Code, 780 CMR SALEM
Revised blar 20/1
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This'Secti6n For Official Use Only,
Build' gPermit er. af.
Btii ding 'ficial Pri i mine), ire- Date _
SECTION1:SIT INFORMATION
.1 Property Address: 1.2 Assessors Map&r Parcel Numbers
(ROaIp
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(11)
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 Cl On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ow�neaof-CRecOrd9'0(-Ke+-4- 0Ig70
me(Print) ,p p City,State,ZIP
. 'I P&T-Mn hC� q7,U SOZ-o7(9 y
No.acid Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK:(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Work': ='J�9 Vle') 11'\QJT Il'1civjj �P�+t>�
nv -iilC f1,xo.2 th IG-I-Gt�e.vi
- VOAr �l-P 2AQc rt.ica.P t�Yc�`r�y ir, W'}ry.o,,, �rv�,ro )mt l��H room
' SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ L/ 0oO 1. Building Permit Fee:$ Indicate how fee is determined:
�. Electrical $ 'j COD ❑_Standard City/TownApplication Fee
❑Total Project Costa(Item 6)x multiplier x
3. PlumbMechanical
( ) $ 2. Other Fees: $
4. hlechvtical HVAC $ Lis[: .
5. Mechanical (Fire $
Su ression) "fotaL411 Fees:$
Check No. Check Amount: Cash Amount:_
6. Total Project Cust: $ 7) O'O CI Paid in Full ❑Outstanding Balance Due:
SECTION 5i CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Ifolder
List CSL Type(see below)
No. and Street Type Descriplion-
U Unrestricted(Buildings tip to 35,000 cu. ft.)
R Restricted 1&2 Family Dwelling
Cityfrown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Tole hone Email address D Demolition
5.2 Registered home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State,ZIP 'Cele hone
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 authorize
t9 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:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest tinder 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.
�Gu�O C(Gf� 9) Z �1 1 3
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 M.G.L.c. I42A. Other important information on the HIC Program can be found at
wvvvv mass govroca Information on the Construction Supervisor License can be found at www.mass.-_ov/dns
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"
1
CITY OF S1ULENI, NLASSACHUSETTS
• B(:I MLNG DEPARTMENT
• P 120 WASHLNGTON STREET, 3'D FLOOR
TEL (978) 745-9595
F.kX(978) 740-9846
Kl,,{BFRt FY DRISCOLL
.MAYORT'HONlAS SY.PiFRRR
DIRECTOR OF PUBLIC PROPERTY/BCILDNG COMMISSIONER
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 it 1.5
Debris, and the provisions of N1GL e 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:
vJ--e
(name of hauler)
The debris will be disposed of in
G3n 1 kk a r0 -T '
name of facility)
-701, Wavt/
(addres. f facility)
4 r��oca�
si nature of permit applicant
/ r27 1 �
date
en �»rra,x
II 1
CITY OF S.U-F.Nf
PUBLIC PROPERTY
DEPARTNMENC
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HONtI OWNER LICLNS6 E.U..%ffj0►V
Pift" "I
Date
Job Loeadot `i f+Tra n t?J S 4" /`t,9 O t 9 Zo
Home Owner Addmse G Q,r-r<i�� 12 r w'L" ✓'t 4 Olt, 70
HomeOweetTelephoos Zg1 SOZ-0-7la4
Present Mailing Address Same c.o C Q3o
he current exemption of"Homeowners"wag extended to include owner-occupied
dwellings of two Units or leas and to allow such homeowners to engsgs an individual foe
hire who doe not possess a lieenso provided that this owner sett as auparvisor.
DEF[NM0N O/H0?aOWNMt
Person(s) *be owns a paned of Lad on which hdshe resides or intends to reside6 on
which then it~ or is intended to bs4 a one or two dltmily dwelling, attached or daubed
Juuctrues accessory to such usg Adlot rum structunrm A person who constructs more
dun one home in a two year period shelf not be considered a homeowner. Such
"homeowner"3W submit to the Building OQ1ci4 on a form acceptable to the Building
Official, that helsho be responsible for all such work pw&rmed under the Building
Permit
The undersigned "homeowner"names responsibility for compliamg with the State
Building Code And other applicable byLws usd regulations.
The undersigned "homeowner'cerdifes that helshe understands the City of Salem
Building Department minimum inspection procedures and requirements and that hdshe
.viIt comply with said procedures and requiremenm
HOMEOWNERS SIG;JATL'RB
.APPROVAL OF WILDING !.r'SPECTO
ice Other side for state coda