4 RICE ST - BPA - � 1
v
--- I he C'onumomvcallh of Ma smichuscus
Board of Building Regulations and Standards CITY OF
Massachusetts St:rtc Building Cole, 790 C'hIR
�1 Building Permit Application To Construct. Repair. Rcnova to Or olish a
vo Our-urrur,-fiiml Dn.•ninx
This Section For 01ficial-c"Yonly /
Building Permit Number: D p t
Buildins 011lcial(Print Matte) Silpl 'n Oale
SECTION I:SITE INFORM TION
L I ropertty Addres��sj) �t /p 1.2 Assessors,Map& Parcel Number
'ILA r0 .fit-- Aim r r�
la Is this an accepted street?yes no Map Number Parcel Nwnhcr
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District 11ropased else Lot Arco Is4 11) Frontage(11)
1.4 Building Setbacks(it)
Front Yard Side Yards Rcar Yard
Re4uired Provided Required Provided Rc4uimd Provided
1.6 Water Supply:IM.G.t.c. 40.J 54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Cr Private❑ Zone: _ Outside Flood Zone?Check if es❑ Municipal On site disposals)stem O
SECTION 2: PROPERTY OWNERSHIP'
2.1 Orr of R^ ord: n
eLe A 01 7 :(O
N;une(Print City,Slate,ZIP
Yi i cc'_ ql-MS--1 d3
No.and Street Telephone Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction Existing Building❑ Owner-Occupied ❑ Repairsls) ❑ Alteration(s) ❑ 11 Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Numberof Units_ Other ❑ Spceiiy:
Brief Description of Proposed Work%
SECTION 4: ESTIMATED CONSTRUCTION COSTS
lical Estimated Costs: Official Use Only
I l.abur a nd Materials) y
I. Building S 1 1. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard CiryiTo,vn Application Fee
❑Total Project Cuslt(Item 6)x multiplier _ -- x
1. Plumbing S 2. Other Fees: S
4. MMI.Inical ill\'.w) S List:
- ----- �-s�---- -mod-�
j. \11-Jmtical iFire S
St + — .-- .--- _-- .-- - --. ..._ . .
rreis ion) rural .\II Fccs: S_
heck No. __('hcck:\muunt: l'.uh \mount:
t� Total Project Cnvl: S d OCJ 04 !❑Paid in Full ❑UulsrmJing Ual:mce Due:
SEX HON 5: CONSI'MicrION SFRN'ICFS
5.1 Con.struction Supervisor License((St.)
I i.Npiraliou Date
401, 1 lolder I sit(.St. r.%P;:(see h6m)
E�Micripflon
livestriowd(Iluiliiiin Ilb to 35,000 ol, IIJ
R lie,iri;:W M2 Fil-il- M-11ill't
Cinifoe—Slalc. %I %lasoll
K Rixifin Co%crin
AS %k ilidim md.li Idi 1111
SF sulid Fuel liuming Appliances
Insulation
1 Donsilition
I vicyllolic _Fmail address
1.2 Registered lionte Improvement Contractor(IIIQ
111C litellistration Number F1111'.11111"Dail:
I 11C Compan) Name or IIIC Registrant Naing
No. and Street Email address
City/Town.State ZIP rdephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152,1 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 .......... E3 No...........0
SECTION 7s: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 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 Nuivic(Elcorunic Signature) Date
SECTION 7b:OWNEWOR AUTHORIZED AGENT DECLARATION
Bye cring my namebelow, I hereby attest under the pains and penalties of perjury that all of the information
' E 0 c,oc
cont tied in this licationi rue and accurate to the best of my knowledge and understanding.
�(Z,)) Z•
"Jer.4 l, nitc
NOTES:
I. Owner who obtains a building permit to do his her own work,or an owner who hires an unregistered contractor
o' I
t "ere have access to the arbitration
not registered in the Hume Improvement Contractor MIC) Program). will la
o reg,
orog or LJJr,
program or guaranty fund under M.G.L.c. 142A. Other imponant information on the HIC Program can be found at
at"
0'.1inrormationon the Construction Supervisor License can be floundat—— 11
11 "1 t
2
2. lien substantial%wrk is pialined, provide the information below:
en SU
r r"t I
ow flour area(.i 011cluailig garage, 11mished basement attics.decks or porch)
a or at
Cross living garea i itt. 11.1 Habitable room count
\umbvr oftlircillaces Number of hedrooll's
Numberkilbadirooms \umber ofliall hall's
lic'Itiog >y sleet Ntlimber pordies
F%I'Vol'0101i'16 i%'tell' Fliclosed
I I oial Project Square Foot-,gc" mad he suhsititited l'or 1*otal Project('list"
11
' 1
CITY OF S.U-E.N1
PUBLIC PROPERTY
DEPARTMENT
�, waasv oaauu
Vwroe t�v�aomt+aM asaeaT•�aK ws�a«ism at��s
HOMEOWNER LICLNSB EXB.It MOY
Plow Mgt
Date
Job Locadan
Home Owner Address
Home Owner Telephone
Present Mailing Address
he current exemption of"Hometownere was extended to include aw ow-occupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
hire who does not possess a Bcenset,provided that the owner sets as supervisor.
DEFINMON OF HOMEOWNMt
Persons) who awne a pwA of Land out which he/she reaides or intends to reWde, 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
"homeownes"shall submit to the Building OQkial,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 bylawa and regulations.
The undersigned "homeowner'certifies that hdshe understands the City of Salem
Building Department minimum inspecridn procedures and requirements and that he/she
Will comply with said procedures and r uirem
HOMEOWNERS SIGMA RE
APPROVAL OF BUILDING ENSPE OR
See other side for state code