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25 RAWLINS ST - BUILDING INSPECTION (2) f� 4 A OV7 S-7 DVS The Commonwealth of Massachusetts CITY OF � Board of Building Regulations and Standards SALEM 47t Massachusetts State Building Code, 730 CMR Revised Slar 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only ' Building Permit Number., Date.Applied: 3 30 l i 1 Building Official(Print Name) Signahue Date 1 V SECTION I:SITE INFORMATION. t 1 ^ L1 Property Address: 1.2 Assessors Map&Parcel Number o_ U I �s� %�i4f (ni5 bT 1.I a Is this an accepted street?yes no Map Number Parcel Number m 1.3 'Zoning Information: 1.4 Property Dimensions: W m O G Zoning District Proposed Use Lot Area(sq ill Frontage(I1) rn Mtn L3 Building Setbacks(R) K Front Yard Side Yards Rem Yard n Required Provided Required Provided Required Provided J= 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❑ On site disposal system ❑ Check if yesCI SECTION2: PROPERTY OWNERSHIP" 2.1 Owner'.FFf=R�of Record: �� `c� . J� � .4Drgrie. iT�1me(Print) City,State,Z4P 2S Auft!NS G' 57& 7sBZWl , cltiFFrlTJt (c t�tr TN No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction O Existing Buildin Owner-Occupied Repairs(s) ❑ 1 Alteration(s) Addition ❑ Demolition Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of PPro�posed\York=: ©'vr-\n air c r ar.ijlf R� �j SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ I. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical $ ❑Total Project Cost'(item 6)x multiplier x 3.Plumbing $ 2 9ther Fees: $ d.Mechanical (HVAC) $ List: 5. \lechanicaI (Fire S Total All Fees:$ Su re5siun) Check No._Check Amount: Cash Amount:_ 6. 'rotal Project Cost: $ (0, 600 ❑Paid in Full ❑outstanding Balance Due: Cl�� (Aj f� izen i 1 SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor Liccuse(CSL) License Number Expiration Date Name ofCSL folder List CSL'Type(see below) No.;rod Street Type - Description . U Unrestricted(Buildings no to 35,000 cu. 11. R Restricted 1&2 Family Dwelling City(Fown,State,ZIP M Masonry RC Rooting Coverin 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 Date IIIC Company Name or HIC Registrant Name No.and Street Email address —Cityrrown,State ZIP Tele hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L:c.ISL§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...........13 SECTION 7a:OWNER AUTHORIZATION,TO BE.COMPLETEU 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 Nance(Electronic Signature) Date SECTION 7b:OWNER'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. d6FnL" 6VtZV 1) 3 30 ( y Print Owner's or Authorized AgcnN I ', Electronic nature) Dale 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. 142A.Other important information on the HIC Program can be found at wwxv.mass.eov:'oca Information on the Construction Supervisor License can be found at www.nt� 2. When substantial work is planned,provide the information below: 'total floor area(sq. ft.) N .(including garage, finished basement/attics,decks or porch) Gross living area(sq. it.) 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 Coolingsystcnn Enclosed Open .1. "Total Project Square Footage"may be substituted for"Total Project Cost" CITY OF SALE M MASSACHUSETTS l BUILDING DEPARTMENT "• r�Y/' 120 WASHiNGTON STREET'3"D FLOOR TEL. (978) 745-9595 FAx(978)740-9846 KIIvIBERLEY DRISCOLL MAYOR THOMAS STTIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING CON2 IISSIONER HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: Date 3 , 3D ' 1 5 \ Job Location Z5 '1 I�S " Aq} Home Owner Address Z S 1'60"95 7!_ S'AZ_W M� AM- Present Mailing Address, � f2A 1-INS 5j Q/',<qI 1 A 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 �d APPROVAL OF BUILDING INSPECTOR ./ Q 1 , QTY OF SALEM, MASSAaiUSEM BUILDINGDEPARTMENT + ._ 120 WASHINGTON STREET,3'm FLOOR I L.(978)745-9595 KAMERLEYDRISODLL FAX(978)740-9846 ' MAYOR 7TrIOMM ST.PIERRE DIRECTOR OF PUBUCPROPERIY/BUILDING MI,MSS70NER 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 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: blkN (name of hauler) Thee) debris will be disposed of in: LI (name of facility) I (address of facility) i natur of applicant Date