16 RIVER ST - BUILDING INSPECTION (2) q I� The Commonwealth of Massachusetts
h } Board ol'Buikiing Regulations and Standards CITY
/) J Massachusetts State Building Code, 780 CMR, 7'"edition OF SALEM
Rrciaed Junu"ry
Building Permit Application'ro Construct, Repair, Renovate Or Demolish a
One-or Tiro-Feunil_v Divelling
This Section For OBicial Use Only
Building Permit tuber: b Applie
J f l
Signature: +�
Building Commissl n /Inspector orb ' i Date
SECTIRNX. SITE INFORMATION
1.1 Pr
to �f ltt✓ope Address• 1.2 Assessors Map 3r Parcel Numbers
Gvt
I.I a 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 11) Frontage(ft)
1.5 Building Setbacks(f)
Front Yard Side Yards 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❑ Private❑ Check if yes❑ p P y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
Y-P )tys C` aeOIioa {gM [-eMS �Itww�
Nm ulie(P}n1) ' Address for Service:
Meaffre Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ E!eisting Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition -9 Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brief Descripti n of Proposeyld�Work�2:: 1
�DAAA,Et�.t 1l ON2Q�A (il,>'l�UivVl�O(� D]PINYL UII
SECTION�4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1. Building S 1. Building Permit Fee: S Indicate how tee is determined:
❑ Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)a multiplier s
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) $ List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
Check No._Check Amount: Cash Amount:_
6. Total Project Cost: $ 41m 0 Paid in Full 0 Outstanding Balance Due:
� y
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number 1?cpiration Dale
Nance of CSI.-I]older
List C'SL'I}pe]see below)
.1 Description
Address 1) 1 Unrestricted(tip to 35,000 Co. FL)
R Restricted 1&2 Family Dwellin
Signature M Masonry Only
RC Residential Rwinut Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
U Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
IiIC Company Name or 111C Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 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........... ❑
SECTION 7a: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.
Signature of Owner Date
SECTION 7b: OWNEW 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 ol'Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations I IO.R6 and 110.115, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.) (including garage, finished basement/anics,decks or porch)
Gross living area(Sq. Ft.) habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halt/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may he substituted fir"Total Project Cost"
CITY OF S.0 &NI, LL-1SSACHUSETI'S
BUMDLNG DEPARTMENT
120 WASHLNGTON STRErm, 3'O FLOOR
` TLzL (978) 745-9595
FAX(978) 740-9846
Ki. BERLEY DR=01.1
MAYOR TiO.&Us ST.PmRa n
DIRECTOt OP PUBLIC PROPERTY/E1:1LEING CONNISSIONER
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 ofMGL-c 40 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 disposal facility as defined by MGL c
l 11, S I50A.
The debris will be transported by:
&NCava,� CA,,.
(name of hauler)
The debris will be disposed of in
YLAI
(name of facility) l
(address of facility)
signature of permit applicant
3 t �
dale
Jcbnvlf JAR
CITY OF SMXENf
PUBLIC PROPERTY
DEPARTMENT
u.u.,ur o.amu
VAraa 1 as WA*w@c o,r swan•ssusa%UnAa&sem oar.o
HOMEOWNER LICEINSE EXEMPTION
Pin" Prlet
Date 3 t tl
Job eaeatim l 4J �renr i eeA
Home owner Address �� •:�e.' sFYeeF
Home Owner Telepboae (u t a s W i q
Present Mailing Address W VA:.rw S A-re f-
The currant 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 who does not possess a lieasse,provided that the owner acts as supervisor.
DF.FINMON OP HOMEOWNER
Person(s)who owns a parcel of land on which hatsbe resides or intends to resider 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
s tomeowner'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"testifies that halshe understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and r iremrnts
HOMEOWNERS SIGNATURE _J
.-kPPROVAL OF BUILDING INSPECTOR
See other side for state code