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12 RIVERBANK RD - BUILDING INSPECTION (2) . + � � , � �he Cummumvcolth uf Massachusette + ;� Doard uf BuilJing Rrgul•rtiuns anJ Standar�s CITY �� Massachusrus State BuiWing CuJe, 780 CMR, 7'"rJi�ion ��F SALEM Rrvisrd Jwruury �� 19uilJing Prrmit Applicotiun To Cunstruct, Rnpnir, Renovate Or Demulish a l. lrxtiv Onr-or Trvu-Fumi/v Owrllrng ( This Sec�ion For O.Rcid Uu Onl � �� BuilJing Prrmit Number: Date Applied: � Signaturt: ��� � � �� NuilJiny C ssione Impeaa uf Buildin�{s I}.�t� SECTION I:SITE INFORMATION � 1^(�%Rerry Ad_drqa�n .. � � / 1.2 A�aason Map& P�rcel Numben YL�1, ��V�✓'z.YU'C__ (Y� I.la Is this an acce ted stree�?yes no Map Number Pn/cel Number I.l Zoa�n�loformatbo: I.J Properfy Dlmeosloos: Zoning District PropoaeJ Ux Ld Aiea(sq Il� Fron�age(fl) 1.5 Bulldlat Setbaclu(R) Front Yard SiJe Yard� Rear Yvd Required Pruvided Requircd Provided Required Provided L6 W�ter SuPPIy:(bf.G.L c.Jo.4 54) 1.7 Flood Zone Intarmallon: 1.8 Sew��e Dbposd Sy�tem: I Zone: Ouuide Flood ZoneT Publie� Private O — Check if a0 Municipd O On�ite dispwrl syslem O I SECT/ON2: PROPERTYOWNERSHIP� � 2.lOwner'otR�,ord�0� ��_ IC�1U�l��(/C/GIAL�/C,L1L . �� � N e(Prinl) A�rcss fa Scrvice: ' _ _2� R� -. -�N�r-�93� Signwure Tdcphoro � SECTtON�: DESCRIPTtON OF PROPOSED WORK�(chcek aU t6�t�pply) New Conatruclion O Existing Buildin Owner-Occupied Repairs(s) O Alteration(s) � Addilion ❑ Demolition O Accessory Bldg.O Number of UniU�, Other O Speciy: � Brief Description of Propoud Work': i l� /�'l � i SECTfON 0: ESTIMATED CONSTRUCTION COST9 Itom Es�imated Costs: 0111c1a1 U�e Only Labor and Materials I. OuilJing S I. Duilding Pertnit Fee: f Indicale how 1'ee i�Jntertnined: ❑S�andard Ci lfown A (icalion Fee ?. Elrctrical S ❑Total Projec Cost�(Item 6)� multiplia x '�( J. Plumbing 5 2. O�her Fen: S i� a. Mechanic�l (fIVAC1 S List: S. Mechani¢al (Firc S Su ression Tutal All Fees:S �r� � Check No. _Check Amount: / 7 -/Cuh Amount: 6. Total Project Coff: 5 � ❑p��d in Full O OutstanJing B�f�ance Due: � 2 �- 7� �(��t..7 't" .F�'.J' "! l ��1 , a , tiECT10N S: COIVSTRUCTION JEKVICES S.1 Llcen�ed Conatrucllon Jupervlaor(CSL) I.icenx Number lixpim�iun IT��e N:une ul'CSI.-I Iu1Jer I.ist CYL�fype 1+�'�bdnw� � Uefcri ion :�JJress U llnmuic�nl u lu 73.000 Cu.Ft. R Res�ric�ed IR2 Fami� Ihvellin tiiynatwe M M (MI � RC Residential Roolin Coverin f.I.pM+ne WS ResiJrntial WinJowanJSiJin SF Re�iJemid Solid Fuel Bumin A lianre Inrmllaiiun D ReeiJtntial Demolition 3.2 Re��tered Home Improremeot Cootnetor(HIC) I IIC Cumpany Name or k11C Regialr�nt N:une Regisuwion Numbn AJJmss � E�pim�ion Date SiynWwe 'felepMx�e SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I�a 152. / 7SC(6)) Worken Comprn�ation Insurance afTidavit must be completed and submined with this application. Failurc to provide this afTid�vit will rcsult in the denial of the Is�uance of the building permi�. Signed AfFidevil Altached7 Ya ..........O No...........O SEGTION 7a:OWNER AUTHORIZATION TO 66 COMPLETED WHEN OWN6(i'S AGENT OR CONTRACTOR APPLIES FOR BUtLDING PERMIT � T �-ta �' , a+Owner of the aubject property hercby aWhoriza �, C.L�.( S to act on my behalf,in all matten «la ' e to work n thorized by t ' ilding p il applicalion. � � 2 Si 'eofOw�rcr Dnte SE OIY 7b:OWNER�OR AUTHORI2ED AGENT DECWRATION �, ��V'� ( ( ,(,(a I(J�/1 � :�/� ,aa Owner or Authorized Agent hereby declerc �het the stetements and info � tion on the forcg ing application arc we and eccurate,to the best of my knowledge and beha �� �_J � �� fl. � P" ` �" 2,3 ?,o C� signa�urt urchv�rc.m n��nuri ngen oa�e Si under ihe aimand Itia of 'u NOTES: 1. A�Owner who ubtaina a building permit�o Jo his/her own work,or an owner who him an unrcgislered cunlroctor (nol rcgistered in�he Home Improvement Contr��or IHIC)Programl. will SQ(have acceu to the arbitration program or guar�nty fund u�dtt M.G.L.c. IJ2A.Other imponanl information on�he HIC Proyram and Construction Supervisor Licensing(CSL)can be found in 7R0 CMR Regulations 1 IO.R6 and 1 IO.RS,respectivaly. �. �� ? Whrn substamial work is planned,provide�he inf'orma�ion below: ' Twal floors area ISq.FI.) (including garage, finished baumentlattia,decks or porch) � Grou living uea(Sq.F�.) Habitable room count Number of�rcplaces Number ol'bedrooms � Numberofbathroomf � NumberoChalf/baths � Type ul'healing sys�em Number of decks/purches Ty�pe of couling eystem Hnclosad Op�n J. "Tu�al Projact Syuare fuomge"may be substi�wrJ lor'?u�al Projttt Cust" -�•.° �,> ' � CITY OF SALLM , , =r _�*, : ,, ��. ,,;.. PL1BLiC PRc�PRERTY '-; ' .='l�" DEP:�R"I'�tENT . .�^i�x v.�•^" ..... t-i: ': ��r.r-� i ,:i __— ... � •,� .,, ,r �': ���.�,iu��..,���i+crr � >.�ii �i. ��.�.;v .:. .; i ., .��� .. . I i i� '�'8�'�;.•i;�i; � I��c 7r8.•J}'i,<a�� ('onstruction Ucbris Disposal ;�ffidavit (rr��uire� fiir �II �icnrolitiun anJ rrnuv:�tiun work) In accordancc ��ith tlic sixth edition uf thc Slatc 13uilding Code, 7S0 CMR scctiun I I l.� Dcbris, and thc provisiuns oF MGL c �0, S 54; (3uildiny Permit i� is issucd �vith the conditiun that thc debris resultin� �iom ihis wurk sh:�ll be dispuseJ ot in a properly licenscd wa,te�lisposal facility as defincd by MGL c l l L S I SUA. The dcbris will bc transportcd by: 1�1 U��ln Si/� CG/°��w.1- �name ot haulcr) I hc Jcbris will be disposed uf in : �(a�-�, S �r � (uamr ul lacihty) �Ci ��il,iuj �'� 7�— � iddress �d�lacililVl .ign�turc uf panuit .ipp cant ���201 � _ _. ,,���.....,..,. � ♦ � . . , CITY OF S.�I.E.�f • PUBLIC PROPERTY DEPART'�iENT . K1fOkYfVetiw.vvi wro. i 3o a�.surw-�a�snFsr• sura�Vwa�ntisarn o�!'0 TtL 9'.L�3�7S9! � F.�t 9'L»0.9iN HOti1EOW�IER LICEYSE EXE.�IPTIO�( Ptew rrt.e Dat� � Zl � � � !ob Laeaaas iV�.Y`'JQ1U� Sc{y�.�yi �� Home Owna Ad�ea� V`2 Home Owoar Telephon� �-1 �(— 3 — — � G ��s�� M T6e curreat ac�paon of"Homaownas"war extrnded w include ownar-oeeupied dwelling�of two Unib or lea� aad to allow auch 6omeownen W engage aa individuat For hire who doa nat possa�s Gcenae,provided that the oana acb ar auparviaor. DEFIIVTITON OF HOMEOWNER Penon(s) who owau�pa�eel otlaod on w6ich hda6e raidea or intend�to raide, on whic6 them i�, or i� intended W be. a oce or two tamily dwalling. attached or detached structura acceseory w auch use and/or farm atructurea, A perwn who conatrucq more chaa one home in a two yeat period ehall not be considarod s homeowner. Such "homeowne�'shall submit W tha Buildin�OfHcial, on a form aeceptable to the Building Of�iciai. that hdshe be responaible for aU �uc6 work performed uadar the Huilding Permit The undmi�ed "homeownd'astuma responaibility for complianca wit6 the Stata Buildin�Code and otha applicable byFlaws and regulatioru. The undmigned "homeownd'cerdfia that hdshe undmtands the City of Salem Bwldin� Dryutrnent minimum inspection procedure� and requiremrnb and chu hdshe will comply with said procedura and requiremmts. HO�tEOWYERS SIGNATL'RE � r � ,�PPROVAL OF 8U(LDf.YG 4rSPECTOR See o�her side for state cade � < ---�-�_� �`'- ,� �� � � \ � \ - � -� � � � � _� .-� � - i I � � � � , � , � , , � � ; --- ��- -� � � � � _ �� °' ,� _ - - I �-- � � ' ���� � o � i, � � -�--- _ i -� � � - S � . ��� I � -�-a -----_ ��� . - �. ,4`� � ��� � S � � � :�t� � :. .�� � l�1 , :> �� _ . . ,� -; , T.. — , r � � �,i.� `0 ` ' s� > :a �:--- 1 , � `� Q -o..,, � - D�, � , ,., �"' ��� � �� i �� - ���... 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