18 RAYMOND RD - BUILDING INSPECTION 0 The Commonwealth of Massachusetts
�l EBuilding
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7'"edition OFSALEM
RevisedJanuary
Permit Application To Construct, Re ' , Renovate Or Demolish a 1, :01A4
On or Two-Fami welling
i Sectia or Official Use Only
Building Permit Number: Date Applied:
Signature: t 1 ({. It 0
C Building missioner/Ins f
for of Buildings Date
SECTION 1:SITE INFORMATION
I.I Pro rty Address: 1.2 Assessors Map& Parcel Numbers
I.In 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 R) Frontage(fl)
1.5 Building Setbacks(it)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.qa,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private[3 Zone: _ Outside Flood Zone? Municipal❑
Check ifes❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
12.1 Owned of Record:
e(Pri _ Address for Service:
Signature U Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Uri Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work 2.1� o m Q .,
A ew 9 C cc,6 w t4L —A
Cs o-�LL r'r (c C rii..h
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Onl
Labor and Materials y
I. Building S 1. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (fIVAC) S List:
5. Mechanical (Fire S
Su ression Total All Fees:S
Check No._Check Amount: Cash Amount:
6. Total Project Cost: S 3 cj 00 13 Paid in Full 0 Outstanding Balance Due:
� I
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL-I Wider List CSL Type(sea below)
rype Description
Address U (Inrestricted u to 35,000 Cu.Ft.
R Restricted I&2 Pomil Dwelling
Signature M Maw Ohl
RC Residential Roofing Covering
telephone WS Residential Window and Siding
SF Residential Solid Fuel Bumin A liance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
IIIC Company Name or HIC Registrant Name Registration Number
Address Expiration Date
Signutum Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.1 2SC(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 ..........0 No...........0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
L�'iw-n, ' ,n�T- as Owner of the subject property hereby
auth rize to act on my behalf,in all matters
re ive to work author' ed by this building permit application.
Si alu o her Date
SECTION 7b:OWNERt OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of 'u
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 Moll have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 11016 and I IO.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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
). "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
LC u'\H II\I...�V)1'N kC r 5.111\I, \t.\K\I 111 .1 I,•.I'1•.
Construction Debris Disposal Afitdavit
(required lur till demulitiun and m-novutiun work)
In accordance with the sixth edition of the State Building Code, 790 CMR scctiun 111.5
Debris, and the provisions of MGL c 40. S 54;
Bud Wing Permit 0 is issued with the condition that the debris resulting from
this work shall be disposed of in a properly ticemd waste disposal facility as dafined by MGL c
111. S 150A.
The debris will be transported by.
mama or hauler)
The debris will be disposed orin :
OIafBe ul nci tly .
I address of 1•acllity)
l
motl4ture of Immit applicam
data
I.Pa•JI.Sr
CITY OF SAL.E.Ni
PUBLIC PROPERTY
DEPARTMENT
KlldlLlYr N.4'.1�
Vwroe '-V W&9oncrow 3nM•SM.M HAMAon.srrn ot9'0
lit 9-8-749-9s"*F. Y.978-746964
HOMEOWNER LICENSE EXE.MMON
Plea"Mail
Date
Job Location
Home Owner Address f ZA n ( a
Home Owner Telephone — — a
Present Mailing Address S S ov
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
hire who,does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Persona)who owns a parcel of lard 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 OtHcial,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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures anj requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code
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REFERENCES :
DEED
PLAN t
I HEREBY; CERTIFY THAT MORTGAGE INSPECTION PLAN
THE /3f//4, ll(53HOWN HEREON
iS LOCATED ON THE GROUND IN
A5 SHOWN AND THAT i -r-
CONFORMS TO THE ZONING
BYLAWS OF THE airy OF
Si9G«� WITH REGARD TO PREPARED FOR
FRONTAGE, AREA AND SETBACKS
AT THE TIME OF CON5TR(KTION e�e/Akl gl rA�V`K 1/q fi -14
AND THAT THE SHOWN SCALE, I " : pia' S�Z �99
HEREON /S NOT LOCAT WITHIN
A FLOOD HAZARD "E
RURAL LAND SURVEYS
DELINEATED ON ,. Ibfi130 CENTRE ST. D4NVERS MA:COMWNITY NO. Z Em /, ,
ASS CHUSETTS.a ESE r NOTE : THIS PLAN SHOULD NOT BE
S 1�5 8Y ., r, ( ,; g3ott) FOR RECON5TRUCTIONJ OF
L I TIOhI t30UNINRY LINES. FOR TITLE
W5URANCE PURPOSES THIS PLAN
HAS NOT BEEN PREPARED BY AN
WE FREDE ICK M.. FORBES P.L.S. INSTRUMENT SURVEY. 117