9 PATTON RD - BUILDING INSPECTION (3) 1
\ The Commomvealth of Massachusetts �i ��� �±�` ���l���w
Board of Building Regulations and Standards CITY OF
S[A�LEM
Massachusetts State Building Code,780 CMR201b NOV 2 IWA%far 2011
�!1 Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Fmnily Dwelling
This Section For Official Use Onl.
Building Permit Number: Date Applted:
14
Building 011icial(Print Name) Signature Date
SECTION 1:SITE INFORNIATIOW
1.1 Propertyo AdJ
Scrl��, F4� nl7�o
ress: 1.2 Assessors biap&Parcel Numbers
1. p;FT t trlca
1.1 a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zuning District Proposed Use Lot Area(sq tt) Frontage(It)
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,§5d) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if esO p po y
SECTION 2. PROPERTYOWNERSHIP!`
2.1 OwnertofRccord: 0( f G` 1 / - 0tC10
e Print city,sstat� ,V`
T�nP+ R —
/� t�hm ( )
ct Q fF—s 7 "2 0-7 6 tf
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alterntion(s) ❑ Addition ❑
Demolition ❑ accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work': <40L7h
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
1. Building S 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard Citylfown Application Fee'
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4.Mechanical (11VAC) S List:
5. Mechanical (Fire $ Total All Fees:S
Su ressiun)
r� Check No._Check Amount: Cash Amount:_
xG. Total Project Cost: S 2�W ❑Paid in Full ❑Outstanding Balance One:
�l� � Yll f�\�.E'D � fib t-1 • Q .
SECTION 5: CONSTRUCTION SERVICES
5.1 Cmtstructiott Supervisor License(CSL)
i
License Number Expiration Dare
Name ofCSL Ilolder List CSL'rype(see below)
Type - Description
No.and Street
U Unrestricted(Buildings no l0 35,000 w. Il.
R Restricted I&2 Family Dwelling
Cityrruwn,Stale,ZIP NI Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone - Email address D Demolition
5.2 Registered home Improvement Contractor(HIC)
HIC Registration Number Expiration Dote
I TIC Company Name or IIIC Registrant Name
No.and Street Email address
City/own,State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L:c.15L$ 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 ..........13 No...........O
SECTION 7a:OWNER AUTHORIZATION.TO BE COMPLETED WHEN..
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERN11T
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:OWNEW OR AUTHORIZED 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 application is true and accurate to he best of any knowledge and understanding.
Print Oweer'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. 142A.Other important information on the HIC Program can be found at
xvww mass.eov:'oca Information on the Construction Supervisor License can be found at ww�'dns
2. When substantial work is planned,provide the information below:
*total Moor area(sq. R.) (including garage,finished basementlattics,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
rypeof cooling system Enclosed Open
3. "I'otal Project Square Footage'may be substituted for"'rokd Project Cost"
>, ti
CITY OF SALEM, MASSAMUSE TTS
i yp BUILDING DEPARTMENT'
ty 120 WASFHNGTONSTREET,3ADFLOOR
TEL.(978)745-9595
KIMBERL.EYDRISODLL FAX(978)740.9846
MAYOR THOMAS STTIERRE
DIRECTOR OFPUBLICPROPERTY/BUILDING CC)AAUSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT.
Date
Job Location ( (PST pjn ooa((
Home Owner AddressSgzj tri s- 0 1 C2 70
Present Mailing Address S w p U
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_ aju
APPROVAL OF BUILDING INSPECTOR
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BUZMCD reXVMrr
uow. s�r,�1
X 745-M.
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Dmscane ca�rmucPaceBlnY/ara�ao�a�
Construction Debris Disposo►/Affidavit
(required forall demolition and..renovition workj
In amrdence with the sbrth edition of the State Building Code, Igo OAM Section 111.5 Debri4
and the provisions of MGL coo,S S4; Bulldlgg Permit fi Is Issued with the
condition that the debris resulting from this work sha0 be disposed of in a properl y►ioensed
waste deposit facility as defined by INGL c 111,S 156A.
The debris will be transported by:
1V�lA � eon&4",
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Sig ature of applicant
c� z1 tI,
Date