9 PATTON RD - BUILDING INSPECTION The Commonwealth of Massac
( 4 Board of Building Regulati dr 5� L" K,
FOR
Massachusetts State Building - e `71 3E��iCES MUNICIPALITY
USE
Building Permit Application To Construct at hsh a Revised Mar 2011
One- or Two-Familyng�� ��r
This Section For'Official Use Onl
Building Permit.Numlier:- Date p ed' - f
Building Official(Print Name) Signa[ure " Date
: .r;' ��SECTION,1: SITE INFORMATION ''
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
�QA-TTOh) IUD
1.1a Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
hZoning District Proposed Use Lot Area(sq ft) Frontage(ft)
t
1.5 Building Setbacks(ft)
_n 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 97' Private❑ Zone: _ Outside Flood Zone? Municipal 2/0n site disposal system ❑
Check if yesO
SECTION 2: PROPERTY OWNERSHH't
2.1 Ow eri of Record:
Name(Print) City,State,ZIP I
I �'�T,�N Rock& � � s1� -076 u
No.and Street Te ephone Email Address
1;SECTION 3:DESCRIPTION OF PROPOSED WORK2,(cbeck all that apply)
New Construction❑ Existing Building 12/ Owner-Occupied t� Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify:
Brief Desc_riplion of Proposed Work : lZ e m lay)P 5
ins�aX! Yl eta Y�eY: , ifl5� c 2j C eAoc CI A g!20a r m,r9
r nm oos�ae -'ciz:m b DUr�y
SECTION 4:ESTIMATED CONSTRUCTION COSTS '
ti Estimated Costs:
Item (Labor and Materials `?w Official Use Only
1.Building $ S 1 Building Permit Fee:-$. _ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ 3
❑Total Project Cost (Item 6)X�mulupher � •-x i
3.Plumbim $
g 2 Other Fees �$
4.Mechanical (HVAC) $ List
5.Mechanical (Fire $
Su ression Total AII,Fees $
Check No Check Amount Cash Amount
6. Total Project Cost: $ "
5 . O"LSZ7 ❑Paid in Full O Outstanding Balance Due:
SECTION 5:4CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone 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 Telephone
SECTION 6:W ORKERS' 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 lad 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: OWNERt 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 the best of my knowledge and understanding.
X U—#� S( ,/>f- i0/ 70/S—
Print Ow ei s or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. 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. 142A. Other important information on the HIC Program can be found at
www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass. og v/dos
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"
CITY OF SALSA MASSAG-ILSEM
% BuiLDn9GDEPAR7wNr
120 WASHINGPON S7REET,31D FLOOR
TUL(978)745-9595.
KIIv>B FAX(978)7400.9846
MAYOR THCMAS STAERxE
D7REGTOROFPUBIJUROPEM/BiIILDMCOMM SIONER
Construction Debris Disposa/Affidavit
(required for all demolition and,renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, 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 deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
( me of facility)
(address of facility)
Si nature of applicant
ate
— v o OTY OF SALEM, MASSACHUSETTS
BUILDING DEPARTMENT`
120 WASI-BNGTONSTREET,3"DFLOOR
TEL. (978)745-9595
FAX(978)740-9846
KIMBERLEYDRISCOLL
MAYOR THOmAS STTIERRE
DIRECTOR OFPUBLICPROPERTY/BUILDING CONMSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date Sn::el . to 1 7rlt, a
Job location eft' n 12(� Sutcw F ffl Or�t 7�
Home Owner Address S�2 c� to so v-e
Present Mailing Address C C ti...Q
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 1 G /I/ T c l�cJl(p
APPROVAL OF BUILDING INSPECTOR