28 RAYMOND RD - BUILDING INSPECTION (3) ;► The Commonwealth of Massachusetts
� If Department of Public Safety
,_,,./ \lassachua•Its Mate Budding C ode 1%8U C�IR)Seernth Edition
City of Salem
Building Permit Application for any Building other than a 1-or 2-Family Dwelling
(rhis traction For Official Use Only)
Budding Permd Numbrc Date Applied: Building Inspector.
SECTION t:LOCATION(Please indicate Block 0 and Lot 0 for locations for which a t d ' n t avai le)
-Z A RenA aclssd 9-6 % A Iakh fnB fA I VO
No,and Street Cite /Toren Zip Code Name of Bu- -'applicable)
SECTION 2:PROPOSED WORK
If New Construction check here O or check,dl that apply in the two rows below
Existing Building❑ Repair❑ Alteration ❑ Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use O Change of Occupancy O . Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineenn eer Review required? Yes ❑ No ❑
Brief Description of Proposed Work: QIACL tY..si I.aG t'aw►T XL*+021e4-
mm,dnAa►.l STAiots
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
Existing Use Group(s): Proposed Use Group(s): P
Existing Hazard Index 780 CMR 34: -- Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-I O A-2r O A-2nc❑ A-3 ❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ 1 H: High Hazard H-1❑ H-2 O H-3 ❑ H-4❑ H-5❑
1: Institutional f-I ❑ 1-2❑ 1-3❑ 1-1❑ M: Mercantile❑ R: Residential R-I&— R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ 5-2 ❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ 11B0 IIIA ❑ 11180 1 IV 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public❑ Check d outside hood Zone❑ Indicate municipal❑ A trench will nut be L)cerned Di,txrs.d Site
raaµnrad ❑or trench or.lw'cdc:
Pt'Ic.)te❑ or Indenufc Zone: ur un•.ire sv4tem ❑
- - permit IN enclu'ed ❑ _
Railroad right-of-way: Hazards to Air Navigation: 'm (...... on H....�.. Pm� :
\ot .lpphiahlc 0 I,�Iruilurc t.Ilhm aopurl approach area' h lhcu rct icu a nnplcl•d'
11, Cnn..•nl w liudd anclu.rd❑ )e,O or No 0 1'r.Cl \o ❑
SECTION 8:CONTENT OF CERTIFICA rE OF OCCUPANCY
I:ddlon,•I(''dr _.._�Lw('wupty: rt pvot Con,uucuon: Occupant loud per 1.(nor
IL¢.the boddmq"alto m.ul tipnnkler}t.tcm': Spraalsupulalon. ,_
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of P i�erly Owner
ohevF1 O, 1i 6WAIL� 2$_f�,l rwtte4 Rd, S�ll.er►Z yYIA OL 1p
%ame(Pt'mU No.and Street Cih'/Town Zip
Properly lie net Contact Information:
OwnKz� cf_*.IqS- —
Title Telephone No.(business) Telephone No. (cell) a-mad address
If applicable, the property owner hereby authorizes
Name Street Address Cih•/Town State Zip !i
(u act on the +ro+erty owner's behalf,mail molten relative W work authorized by this buildin• permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(It t•uildin is 4tys than 33,0)Ucu.it.of mcloead< ace and/or not under Construction Control then check hers O and slu Sts:tion I0.1)
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
.3L,F.
Company Name:
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'C MPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 2506))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1.Building $ Pill Building Permit Fee=Total Construction Cost x—(Insert here
2.Electrical $ appropriate municipal factor)=$
3.Plumbing $
4. Mechanical (HVAQ $ Note:Minimum fee=$ G (contact municipality)
5. Mechanical (Other) S Enclose check payable to
6.Total Cost S (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I herebv attest under the pains d penalties of perjury that all of the information contained in this
appincatwn is true and accurate to the best of my nowlecig d understanding.
11
I'te.ne f, I.and,.g;n n.yme title Telephone\u Ua(e
28eta—l—wwhd ►2ofrT] S9A 1570
';Iwet lddrell City;Tutcn State Zip
Municipal Inspector to fill out this section upon application approval:
\ame U,rte
CITY OF SALEM
• PUBLIC PROPRERTY
DEPARTMENT
M I h l ! Kim r r 1 1
TO/S.\I Ill, MA%" I
'frl:'/78.7�."t•Yiys I l'.\.'(:978.740-9846
Construction Debris Disposal Affidavit
(required fur 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 MGL c 40, S 54;
Building Permit I! _ _ is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
ll1. S 150A.
The debris will be transported by::
14,
I name The debris will be disposed of in
ut hauler) :
(name of as ity)
(address of taclfity)
,ignamre of txnnit applicant
2 V zo�G
date
Ichr r.dl Arm
CITY OF SALE.*vi
PUBLIC PROPERTY
DEPAR'I'AMENT
Kl1allliY O�waL. i
Mwroft 1311 WA91W.ROOM hull 4 14AK MAnAcHLsrm o»'e
TM 9:a•7+lAS"•FA)L 9'L7g7W
HOMEOW,NER LICENSE EXEMPTION
Please Print
Z4/B
Date 5 2
Job Locadoa `Z$`�ce�/irc�,, d 02c�/
Home Owner Address 'z /<+,, ~, C, o S4 eT„
Home Owner Telephone 'Me--7 v -0 2
Present Mailing Address -Z i 2 .//� C✓ Sd 7
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 act@ 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 bo, a one or two family dwelling, attached or detached
structures accessory to such use and/or farm structuree. A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner"shall submit Ito 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE
,APPROVAL OF BUILDING INSPECTOR
See other side for state code