16 RIVER ST - BUILDING INSPECTION (4) p 1i
J�) The Commonwealth of Massachusetts
V Town of
J Board of Building Regulations and Sta Bards
Massachuscns State Budding Code, 780 CN , 7'"edition Building Dept
Budding Permit Application onsiruct, Repair, enovale Or Demolish a
Oae- r Tu -Fain Du'clI rig
is Sect n Fo Met Use Onl
Building Permit N miser Applied:
Signature: I
Building Commuss Inspector of Bull n Due
SECTIO :SITE INFORMATION
r 1.1 Property Address: 1.2 Assessors Map• Parcel Numbers
I to titre - 4h-eoi-
I.la Is this an accepted street?yes no Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq fl) Fronisge(fl)
I S Building Setbacks(D)
Front Yard Side Yerds Rear Yard
Required Provided Required Provided Required Provided '
1.6 Water Supply:IM.G.L c.40.154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: ,_ Outside Flood Zone? Municipal O On site disposal system D
Public O Private O Check if sCI
SECTION 2: PROPERTYOWNERSHIPI
(/\ 2.1 Ownertpf Record: I Ri` itr r Si re��
Na t) ` Address for Service:
6l-q--}gi2 -L/
Sign& Telephone
SECTION l:DESCRIPTION OF PROPOSED WORK'(check sill that apply)
New Construction O Existing Building O Owner-Occupied O Repain(s) O Alteration(s) O Addition O
Demolition O Accessory Btd{.O Number of Units_ Other O Specify:
Brief Description of Proposed Work*: I A S
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building f 000 I. Building Permit Fee: S Indicate how fee is determined:
O Standard City/Town Application Fee
2 Electrical S O Total Project Cour(Item 6)a multiplier s
) Plumbing S 2. Other Fees: S
a. Mechanical IHVAC) $ List: ( )
s tlechanical (Fire S Total All Fees. S
Su rescion
Check No. _Check Amount: Cash Amount:_
L 6 Total Project Cost S )l 006 O Pad in Full 0 Outstanding Balance Due-
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
,. Liceme slumber Esptration Date
N,Y�tat CSL- )lylder il.i,i CSL Type(xv tw luw)
a — .
AJ4esa T Description
U Unrestricted(up to f3,000 Cu. Ft
R Restricted 1h2 Family Owetlm
Siarumre N %lasoncry Only
RC Residential Roofing Covering
Telephone 'S Residential Window and Siding
SF Residential Solid Fuel BurrinX Appliance Installation
D I Residential Demolition
3.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Addrm
Expiration Date
signature Telephone I i
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. ISL 12SC(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this ailidavit will result in the denial of the Issuance of the building permit.
Signed ARidavit Attached? Yes.......... O No...........O
SECTION 78: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.
SignattaofOwner Data
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
I, K2 Yr k-f YK 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.
Ive 1/64a K trews
Print N
Si o Owner or-Authorized Agent Date
(Soccried under the pains and penalties of r-
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 do have access to the arbitration
program or guaranly fund under M.G.L. c. 1 a2A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110,R6 and 1 10 RS,respectively.
2. When substantial work is planned,provide the information below:
Total Doors area(Sq. FL) (including garage, finished basemenvattics,decks or porch)
Gross living area(Sq. Fl.) Habitable room count
Number of fireplaces Number of bedrooms
`umber of bathrooms Number of halfbaihs
Tvpe of heating system Number of decksi porches
Typeofcoolingsystem Enclosed Open
1 "Total Project Square Footage"may he.uh.otuted for 'Total Project Cost"
ti
CITY OF S.U.E.Nf
PUBLIC PROPERTY
DEPARTMENT
UfOkJLY7 NM.'.Y
Vwrw i30w�sw+[.�'aMS7't�ii93�ua�Nwa�aRs�rrso�970
TEL ra-7+5-9s"0 FAX 979.74&9W
HOMEOWNER LICENSE EXE.MFTION
Plus Met
Dam 2 - e) - 10
Job Location 16 R i vt y 5 tre +- a l e vtn
Horne Owner Address 11,9 2 i u�,r 4N--"+ S ra le vv
Home Owner Telephone h 1-3 - 9 2 - H i 4 0
Present Mailing Address 16 R i ur y- st-v e.+ Sa to w, 01 a}o
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 who.does not pow=a Geerue,provided that the owner act@ as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a panel 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"ass uses responsibility for compliance with the State
Building Code and other applicable by-laws and reguladons.
The undersigned "homeowner"certifier 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
s� CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.I•,r:: xl ri �•xlw r.0
\I11 'It I'0�'.liIIIKGI0.^ISI'xFL'T S.11I'%1- %1.\u.\I III
IYI:W1.743.9395 F%x:978•74049x46
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 I 1 I.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit 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
111. S 150A.
The debris will be transported by:
wall-e Mav�a ce tnncln�-
(namc of hauler)
The debris will be disposed of in
(name of act 1ty)
(address of facility)
.i aturc of permit applicant
date