9 RIVERBANK RD - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
y, Board of Building Regulations and Standards CITY OF
'r Massachusetts State Building Cute, 730 C'fvlR SALEM
Revised.l her•2011
Building Permit Application 'fo Construct, Repair. Renovate Or Demolish a
OAIe.or Ttvu-Purnill Divelling
Fhis Section For Official Use only
Building Permit Number: D I A pf•d:
+GN�agLL vTrl�1 ,� 6.4 ---
1111ilding Official(Print N;unc) , igtature Date
SECTION I:SITE INFORNIATION
1.1 S
Pro erI AJtK;yetJyess: —h II464 lid/ alem 1.2 Assessors M1lxp di Parcel Numbers
L la Is this an ucce ted street?yes no M9 Map Numter Parcel Number
I.� Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed(Ise Lot Arco Isq II) Frontage(II)
1.5 Building Setbacks(R)
From Yard Side Yams Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L u.qg,§Sq) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Lone? Municipal❑ On site disposals)Check if —1 P posal s stein ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
S41em Mkt Ol`J7U
N;unc I Pn°q cip..State.ZIP
9 Rive 4,1,7 r
No.and Sired Telephone Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition Cl
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ I Other ❑ Specily:
Brief Description of oposed \Vor
SECTION J: ESTIJIATBD CONSTRUCTION COSTS
Itdtt Estintaled Costs:
(Labor and \laterials) 011lclol Use Only
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
2. lilearical S ❑Standard City/Town Application Fee
❑Total Project Cost'I(tent 6)x multiplier _. x
1. I'lumhi°g S '. Other Fees: S
J. %lechanica1 11 \.w) S Lisl:
Culvcssiont S Total .\Il Fccs: S
o. Total Project Cost: S r ('hak No. -- —('heck Amount: ('ash \m,nml:
Ai J (TU 6 0 Paid in Full p UutsrmJing Ilal:mce Due:
SEX PION 5: CONS I-Ritic'noiN SERVICES
5A Construction Supervisor License(CS1.)
I icoise Number viratioll Date
Name of 01, 1 loltler I is[CS1. I PC(we helots)
I,)PC Description
No, and street (I I Inrvstrioed(Iluildings uJP In 31J000 St. 11.)
It Itctricted 1&2 Famil) I %w1lillitt
k1I N111,4,111111 f
RC R,xifin Coverin
WS window and Sidiog
SF Solid Fuel Miming Appliances
I hlsulaiun
I'CIePhollc Finail address D
Denusliliun
5.2 Registered Home Improvement Contractor(HIC)
lilt Itegigration Nuni[Scr Tqllratllln We
IIIC Compan) Name or IIIC Registrant Name
No.and Street Ennuil address
City/Town.State,ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L It. 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 ..........0 No.........
SECTION 7@: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 an my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Nwlie(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below.I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
�gj 40- t<e-a nz---
Print 0micir'i or Atillionled Agent's Name(Hectronic Signature) Date
NOTES:
I n Owner ,%hu obtains a building permit to do his,her u%vn Nvork,cran owner who hires an unregistered contractor
itiol registered in the Hume Improvement Contractor(1-110 Program),will no have access to the arbitration
program or guaranty fund under M.G.L. c. 142.A.Other important information on the HIC Program can be found at
t%%% ;ok ot a Information on the Construction Supervisor License can be round at tt%S,% n%',; ^ III,
2. \N lien substantial work is planned,provide the infurmatiun below:
row t1our area IS+ A I including garage, finished bascinentattics,decks or porchi
Cross it%ingarea i sq. tI.I habitable room count
NtI111110 Of fireplaces Number of bedrooms
Number ol'bathrooms Number of hall'haths
Number ot'decks, porches
" I'ndosed Op
I ell
pe ofCoolilig i.%Steil)
be Substituted I'm-I'tital Project Cost-
CITY OF SMYL Nt
.I Is
PUBLIC PROPERTY
DEPARTMENT
I'M 9WAS-Isis•R,t f'L7adfW
HOMEOWNER LICENSE EXE.MMON
Pleaw Met
lob Locadois-
lives t �,
Home Ownw Telephone 9 7 r— 7 SAS 8 3
Presser Mailing Address .S 61 m e ,
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or less and to allow such homeowners to engsgs an individual for
hire who.dos not possm a Ileenso provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Persons)who owns a parcel of Lod on which he/she residss or intends to reside.on
which there it, or is intended to be6 a one or two f usi ty dweWngu athehed or detached
structu m accessory to such use and/or farm structure. 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 Weill,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 impaction procedures and requirements and that he/she
Mill comply with said procedures and requirements.
HOMEOWNERS SIGNATLRE
APPROVAL OF BUILDING INSPECTOR
See other side far sill@ code
CITY OF S,UZN(q LY Lus.kcFj USE i l J
f3ltLOI.VG DEP.IRTIF,\T
I_'0 W.liH6VGTON STRW. Ya FLOOR
TIRL (978) 741.9591
K)J®ERr Y ORMOLL FAX(973) 740.9&$4
MAYOA I}tOSW ST.Ftanfts
Dutaaa4 OP Pl'atic PROPEriTY/glQ,pL%jC G0101fSE(O,V Elt
Construction Debris Disposal At'lidvit
(required for all demoliU04 and renovation work)
In accordance with the sixth edition of the State Building Code, 790 CMR section 1 I I.J
Debris, and the provisions of MOL a 40, S 54;
Building Permit At ibis work shall be is issued with the condition that the debris resulting from
S 1 JOA. disposed of in a properly licensed waste disposal facility as d08ncd by,�lOL c
111,
The debris will be transported by:
(name of hauler) t�� r�rJ/�/
The debris will be disposed of in :
(name of fa-�j
(iddrar of f�ml uY)
"y�n+ro ofpermit�ppliunt
,:ire ----