55 RAYMOND RD - BUILDING INSPECTION C 7/(, L/
fh�r� t�ltlyg�Massachusetts TRe
ITY OF
Board Ht hI4LRsA[� tandards ALEM
Massachu��s��epptts State Building Code;'780 CMR d,Wur 2011
Building Permit Applic?f&Q&lU:atrtP Rgp��jjr Renovate Or Demolish
One-or Two-Family Dwe7prg
This Section For Official Use only
Building Permit Number: Date Applied 'Z Ai
Building Olticial(Print Name). Signature Da a `J
1 SECTION 1:SITE INFORMATION:
1:1 _opertX Address: 1.2 Assessors Map& Parcel Numbers
I.1 a Is this an acce ted street9 yes no Nlap Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
_ Zoning District Proposed Use Lot Area(sy fl) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard - Side Yams 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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public(3Private❑ Check if es❑ P Po y
SECTIONZ: PROPERTY OWNERSHIP!'
2.1 wneri of Record:
NN me(Print) City,State,ZIP /I
J 97� 37 �.Z/6 �ai v �oTF e'o err; � cow
Nu.nnJ Slrcct Telephone Email AdUmqq
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ 1 Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ NuniberofUnits_ I Other ❑ Specify:
Brief Description of Proposed Work=: r J Fec.do f
;r
SECTION a:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials -
I. Building S 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 17.9ther Fees: S _
t. Mechanical (HVAC) S List:
5.Mechanical (Fire S "total All Fees:S
Su ressiun)
k Check No. Check riniount: Cash Amount:
66...,To�ta1l Project Cost: S /Y 0� k ❑Paid in Full 13 Outstanding Balance Due:
/ANT 1�(p ( l�
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holler List CSL Type(see below)
Type Description
No. ;md Street
U Unrestricted((Buildings tip to 35,000 cu. 11.)
R Restricted l&2 Family Dwelling
Cityrrotvn,State,ZIP M 1\4asonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Enail address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Cumpony Name or HIC Registrant Name
No. and Street Email address
Cityrrown,State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. I5L§ 25.0(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 7a:OWNER AUTHORIZATIONTO BE COdIPLETED WHEN. i
OWNER'S AGENT OR CONTRACTOItAPPLIES FOR BUILDING PERMIT
1,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
contain in this application ' t e and accurate to the best of my knowledge and understanding.
2-
Print Owner's or Autli razed Agcnt' ame(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to Jo his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(1-IIC) Program), will not have access to the arbitration
program or guaranty fund under I.G.L.e. I42A.Other important information on the H[C Program can be found at
w""cowww mass.eov:'oat htronnation on the Construction Supervisor License can be found at www.nriss. ,ov-!dm .
2. When substantial work is planned,provide the information below:
Total floor area(sq. R.) (including garage, finished basementtattics,decks or porch)
Gross living area(sq. R.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type or heating system Number of decks/porches
Type of cooling system Enclose) Open_
1. "Total Project Square Footage"may be substituted for`"rot;d Project Cost"
QTY OF SALEM, MASSACHUSETTS
BUILDING DEPARTMENT
120 WASHNGTON STREET,31OFLOOR
J TEL. (978) 745-9595
\.mxv
FAX(978) 740-9846
KINIBERLEY DRISCOLL
MAYOR TYfOMAS ST.PIE RRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMbIISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date
Job Location i- V�a c/ 6+a a!+ ) I o<+ d �4 I -e I i>�A' ell
�a
Home Owner Address J� Al P7 D/9�3'�
Present Mailing Address Z. z
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 ACA
APPROVAL OF BUILDING INSPECTOR