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17 1-2 RIVER ST - BUILDING INSPECTION �- I tt --7 " 7�Q- C �31 © The Commonwealth of Massachusetts RECEIV D Board of Building Regulations and Standards INSPECTIONAL SERVICESIF Massachusetts State Building Code, 780 CMR SALEM Revised Mar 2011 Building Permit Application To Construct, Repair, Renovate Orftrohpl A P 2b One- or Two-Family Dwelling This Section For Official Use Only r E k V Building Permit Number: sate poliedi Building Official(Print Name) Si nature Date - SECTION 1:SITE INFORMATION 1.1 Prod dress:rty All 1.2 Assessors Map& Parcel Numbers I� �i AVER `J IzEET SALEM l.la Is this an accepted street?yes no Map Number Parcel Number. 1.3.Zoning Informations. 1.4 ,Property Dimensions; Zoning District Proposed Use Lot Area(sq ft) Frontage III) ..- 1.5"Building Setbacks(ft). -' 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:! Public❑ Private - Zone: _ Outside Flood Zone? . Municipal❑ On site disposal.system ❑ Check if yes[] - - - SECTION 2: 'PROPERTY OWNERSHIP' 2.1-Owner'of Record: t::t2Epa-rz-ICGc DilE6C—r�FFEfME� liaLEM MA - Oldj -10 Name(Print) City,State,ZIP L� �i �IVEr� 511+�c-r 612 -rc prec-i5iO'n; � .ne+-' No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building Owner-Occupied 0 Repairs(s),HI Alteration(s)V .Addition ❑.,- - .. Demolition $ Accessory Bldg. ❑ Number of Units Other ❑ Specify: :.._,.. Brief Description of Proposed Work': 12-C-NoyAT6 "I" r-L, bs1 LWJ06> Sp,&-Gr I N 5 TAIL I NSJI-din s1J f N Ro e� OrAJ �-/Q./.LS I N S�f N E� (ioo�016 � urtE.R-S pr<aPaa.n t�rG-R-twr- �r�Rs — SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ 3 00 0 g .... _ 1. Building Permit Fee: $ Indicate fee,is determined: ❑Standard City/Town Application Fee 2.Electrical $ (' O 60 - ❑Total Project Costa(item 6)x multiplier x 3. Plumbing $ 060 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5. Mechanical (Fire - ' .... : , Suppression) $ Total All Fees: $ - Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ 1 000 ❑Paid in Full ❑Outstanding Balance Due (Wig► L la O . �l SfbiRIc- UvR— (D0 FIuG M►,l es SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder List CSL Type(see below) No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft.) R. Restricted 1&2 Family Dwelling City/Town,State,ZIP - - - M Masonry - RC Roofing Covering WS Window and Sidin - - SE Solid Fuel Burning Appliances .. .,._ I Insulation iTele hone Email address D -. .Demolition. 5.2 Registered Home lmprovement Contractor(HIC) - HICRegistration Number Expiration'Date. .. , HIC Corripany Name or MC_Registrant Name " No and Street- .. -- Email address City/Town;State,ZIP Telephone SECTION 6:WORKERS COMPENSATION INSURAN CE.AFFIDAVIT(M.G.L.c.152.§ 25C(6)) . . .... ..,_ . _ ' Workers Compersation Insurance affidavit must be completed and submitted with thisapplication.-Failureto provide- this affidavit will result in the denial of the Issuance of the building permit. ,- g v .. .<. .❑' Si'ned A�fffdavit Attached Yes .:r......: ❑' Nd : t: ,,t •' SECT� ION 7a: OWNER AUTHORIZATION Tl):BE COMPLETED WHEN OWNER'S'AGENT OR CONTRA CTOR,AEPLIES'.FOR BUILDING PERMIT I,as Owner of the subject property,hereby.authorize . - - " to act on m behalf:in all matters relative to work authorized by i ths,builn - Y.... _ di,.. gpermitapplica[ion. . . _ . . ... Print Owner's Name,(Electronic Signature). - SECTION 76: OWNERt OR AUTHORIZED AGENT DECLARATION -' . '.,,. By entering my-name below„1 herebyattest under.,the pains and penalties of perjury-that all of the information contain this app ' anon is true,and accurate to the best of my knowledge and understanding: Print O ner's or Authorized Agent's Name(Electronic Signature) Date. NOTES. ------ - -I: An Owner who obtains a building permit to do-his/her-own-work,"or an owner who hires an unregistered'contractor-, -r r (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 can be.found at . www:rnass.-oOoca Information P ormation on the Construction Su ervisor'License can be found at www.mass."ov/dos ` . _ . 2. When substantial work is planned, provide the information below: _ " Total Floor area(sq.ft.) - - - "" " (including garage, finished basement/attics,decks or porch) " Gross living area.(sq.ft.) Habitable room count . .. . . Number of fireplaces - Number of bedrooms_ _ _ Number of bathrooms - - - -- - Number of half/baths , - Type of heating system Number of decks/porches Type,of cooling system "- - Enclosed Open - - - - - 3. "Total Project Square Footage" may be substituted for"Total Project Cost" - - CITY OF SL] .&M, N'LAsSACHUSETTS • BtimmNG DEPARTMENT \ o a 120 WASHIDIGTON STREET,3m FLOOR TEL (978) 745-9595- - Fnx(978) 740-9846 KIJiBERLEY DUSCOLL ANYOR THowsST.PIERRE DIRECTOR OF PUBLIC PROPERTY/BL'1LDn4G COJL iISSIOYER Construction Debris Disposal Affidavit (required for all demolition and renovation work) ]r accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 .Debris .and th8.provisions"of MGL:c'-40;_S'S4,:. Buildiog'Perly'fld# is issued with the condition that the debris resulting from this work shall be'disposed,of to a properly licensed waste disposal facility as defined by MGL:e l 11;S-f 50A. ` ` "'`'The debris will-be'transportcd by. h r p .. . OEM ' r % "•. .,G�1 r .l � � is /• .; ;Er AA :M)10( (name of hauler) The debris _ _ ... ...... will be disposed of in _,... . . ., -- (name of facility) ,. ,.,. ,,:, .n•; - „i . ...,-(address offacihfy) ...,,.. .,.:: . . . signature of permit applicant .. . .: _ date tn „�tr.dk1' QTY OF SALEM, MASSACHUSETTS BUILDINGDEPAR I1 ENT I fir , 120 WASHINGTON STREET,3�FLOOR \M TEL. (978) 745-9595 FAX(978) 740-9846 KIMBERLEY DRISOOLL MAYOR THOMAS STTIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: y Date 4 , I I - `r Job Location 1-1 '7- IZ-1 I/j5�- AA A- old -7 0 Home Owner Address `2� Present Mailing Address <Alm � 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 APPROVAL OF BUILDING INSPECTOR