16 RIVER ST - BUILDING INSPECTION The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards 1111900m
Massachusetts State Budding Code. 780 CNIR. Pa edition Budding Dept
` Building Permit Application To Construct. Repair. Renovate Or Demolish a
One. or Tiso-Famrls•DVvellmg
Angola
is Section For Official Use Onl
Budding Permit N an Date Applied:
� n2p/�o
Signature: -
Bwlding Commissioner/Iasprci flillinits Dam
s T ON 1:SITE INFORMATION
.1 Propperty Address: 1.2 Assessors Map& Parcel Numbers
Ho M-VKK St- Parcel Number
I.I a Is this an ace eed street'!yes no Map Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning Dinnce Proposed Use Lot Area(sq tlq Frontage(n)
1.3 Building Setbacks(0)
From Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,154) t.T Flood Zone Information: 1.4 Sewsga Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Public O Private O Check if s0
SECTION 2: PROPERT WNERSH1Pi
nerr of Record: (6 Ri
2v F
me Print) for Service:
AZlol- - ��2• NI40
Signature 'L Telephone
SECTION l: DESCRIPTION OF PROPOSED WORK'(ebeek all that apply)
New Construction O 1 Existing Building O Owner-Occupied O 1 Repsirs(s) O Alterstion(s) Cl Addition O
Demolition O I Accessory Bid#.O 1 Number of Units_ Other O Specify:
Brief Description of Proposed Work': UoAANi 1044-k Oom - new i-ubi thew {ri44
i OVA101 fro ♦ate 11e t 1
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: OlReial O
I. BuildingBuildingnly
Item Labor and Materials
f d i'60o vo- 1. Building Permit Fee: f Indicate how fee is determined:
O Standard City/Town Application Fee
2 Electrical S 0 Total Project Costs(Item 6)x multiplier x
Plumbing f 2. Other Fen: f
i. .Mechanical IHVACI S List:
t Mechanical iFire S Total All Fees: f
Su ression
Check No. _Check Amount: Cash Amount:
n Total Project Cost S / — 0 Paid in Full 13 Ouisundmg Balance Due
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License..Number Espa.roon Mic
Nfoa of CSL Ilplder Lost CSLType Isee helowl
Address WResi5dential
Description
tricted u to)5,000 Cu. Ft
ted 1&2 Fatnd Dwelhn
Sid"fute Unl
ntial Rooln Coverm
Telephone ntial Window and Sidm
tial Solid Fuel Bumm Appliance Installation
tal Demolmon
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.# 23C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
Ihis afdsvit will result in the denial of the Issuance of the building permit.
Signed AMdavit AttacheJ9 Yes.......... 0 No........... O
SECTION 72: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.
Si stove of Own Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
I. k 2U i ✓1 5 yy-P-Pei SS a 14 e VI kzm S 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
behal
ke y vvet iv,ct I-tannkevts
Print N
I - tq - to
Signature of Owner or Authoozed Agent Date
(Signed under the pains and pinalties of
NOTES:
1. 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 Sg 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 780 CMR Regulations I I0.R6 and 110,RS, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/aitics,decks or porch)
Gross living area(Sq. F0 Habitable room count
:Number of fireplaces Number of bedrooms
Number of bathrooms Number of half baths
Type of heating system Number of decky porches
TYpeof cooling systern Enclosed Open
1 "Total Protect Square Footage"may he suh.lituied for 'Total Protect Cost'
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
Ill Xl hl '•NIr '41
I IC VI'.\QII\L:�1V)1'N kr7 0)•\I111, )t.\si.\l -
l'Pl: '1711-743-9iy5 • 1:.\X:978-7*984fi
Construction Debris Disposal Affidavit
(required flor all demolition ahhd renovation work)
In accordance with the sixth edition of the State Building Code, 780 CbIR section 111.5
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
I11. S 150A.
The debris will be transported by:
ilJan�e IU�n�a�e
(name of hauler)
The debris will be disposed of in :
(mine o1 aci rty)
(aJdrcss of lircility)
Al=
sigi,ure I f permit app 1•ant
(late
I.bn.d(d,ti
CITY OF SM.E.Ad
PUBLIC PROPERTY
DEPARTNLENT
W` 130 WAswr lmN ftW=•SALEK VAMAOHLSUM 019-0
Tti V&743,4s+s• F.4x 978.7+o.9646
HOMEOWNER LICENSE EXEMPTION
Pkaa "It
Date ( . M . 10
Job Location LI (b River 51 ee k O(q�U
Home Owner Address 110 2.i v e v- e-tyee F OM 1-0
Home Owner Telephone 0 t --,C 2 -4 1 4 o ✓
Present Mailing Address 10 otR�0 c�
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 possess a licenser provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Persons) 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
,.Pill comply with said procedures and requirements. /
HOMEOWNERS SIGNATLRE /1 l/
APPROVAL OF BUILDING NSPECTOR !/
See other side for state code