12 RIVERBANK RD - BUILDING INSPECTION I. Li-7 1
The Commonwealth of Massachusetts
Board of Building Regulations and Standards RECEIVED CITY OF
Massachusetts State Building Code, 780 cIMPECTIONAL SE VICETLEM
_ Revised Mar 201l
Building Permit Application To Construct, Repair, Renovate Or oli h
One-or Tivo-Family Dwelling �I4 � Y 08
This Section For Official Use Only
Building Permit Number: D e Applied:
Building Official(Print Name) Signature pate
SECTION 1: SITE INFORMATION
I,.I Property e�t` `—— — 1.2 Assessors iYlap& Parcel Numbers —
-I Id n a Is this a accepted street'?yes no Map Number Parcel Number I
1.1 7osin�g :nf o'niatimc _—_
.. , L! Yrr.:ec!iy rli!n C!es4on,:
Zoning District Prolxtsed Use Lot Area(sq ft) Frontage(a)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(iYI.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Cl Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal❑ On site disposal systen! ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Owner Iof R_ec�ord � -� 0
e(Prin) Citue.ZIP�
No.and Street )rleEmail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specily:
Brief Description of Proposed Work:
X - -
SECTION d: ESTIir1ATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
I. Building $ I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical $ ❑Standard Cityfrown Application Fee
❑Total Project Cost'(Item 6)s multiplier x
3. PlUmMechanical
is $ 2, Other Fees: $
Mecha
4. anical (I IVAC) $ List:
5. Mechanical (Fire
Su )ression) $ Total All Fees:
(i. Total Project Cost $ Check No. Check Amount: _Cash Amount:
X I" ❑ Paid in Full ElOutstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
y.
t 1 ' 4j.t'f' 'y. License Number L'xpi ration Date
Name of CSL Holder
List CSL'Pype(see below)
Nu.and Street FyPe Description
U Unrestricted(Buildings up to 35,000 cu. 11.)
CitylFown,State,ZIP R Restricted 1&2 Finally Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(11IC)
r
HIC Registration Number Expiration Date
f IIC Company Name or IiIC Registrant Name
No.and Street Email address
Ci[ /'Town, State,ZIP "Pete hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 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 .......... ❑ No ...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW ORAUTHORIZED AC ENT 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.
Prua Owner's ur AuthorizcJ Agent's ume(Electronic Signature) Date
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 [Ionic Improvement Contractor(HIC)Program), will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.eov/ocu Information on the Construction Supervisor License can be found at www.nmss.eov/dns
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage, finished basemem/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"Focal Project Cost"
i�
CITY OF SALEM, MASSACHUSETTS
BUILDING DEPARTMENT
120 WASHINGTON STREET,3RD FLOOR
TEL. (978) 745-9595
FAX(978)740-9846
KINMERLEY DRISCOU
MAYOR TrIOMAS STTIERRE
DIRECTOROF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date I /
Job Location t 66 R
Home Owner Address tea IQ tq4o!�/10,k-
Present Mailing Address C r
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 j
APPROVAL OF BUILDING INSPECTOR 'O v���"