15 ROOSEVELT RD - BUILDING INSPECTION The Commonwealth of Massachusetts Town of
Q Board of Building Regulations and Standards
aJ Massachusetts State Budding Code, 780 CMR, 7'a edition Building Dept
Building Permit Application To Construct Repair, Renovate Or Demolish a
One-or ru o-Hindi Dive-fling
Th Section For Official Use Only
Building Permit Numbe
Signature: r!J�2 6l JT_
Budding Co sst n for of Buildings Date
11 SECTION 1:SITE INFORMATION
1.1 Pro Address: 1.2 Assessors Map tit Parcel Numbers
� �oSr�ieL� —
L I a Is this an accepted street?yea no Map Number Parcel Nit
umber.
Zoning Information: 1.6 Property Dimensions:
Zoning District Proposed Use La Arca(sq fl) Frontage IR)
I.S Building Setbacks(ft)
Front Yard Side Yards Rem Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c. ail,f Se) 1.1 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Munici al O On site disposal s stem
O O
Public O Private O Cheek if s P Y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ow of Record: S
e(Pri t�' / �i Addre eivice:
1l,� /(�
Signat ure Telephone
SECTION l: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building O Owner-Occupied O 1 Repairs(s) O Alteration(s) O Addition Cl
Demolition O Accessory Bldg.O I Number of Units_ I Other O Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Ofncial Use Only
labor and Materials
I. Building f 1. Building Permit Fee: f Indicate how fee is determined:
O Standard City/Town Application Fee
2 Electrical f Cl Total Project Cost'(Item 6)x multiplier x
J Plumbing f 2. Other Fees: f
4. Mechanical (HVAC) S List:
s Mechanical (Fire S Total All Fees. f
Su ression
Check No. _Check Amount: - Cash Amount:_
h Total Project Cost: f S7J'r 00 0 Paid in Full 0 Outstanding Balance Due'
SECTIONS: CONSTRUCTION SERVICES
*Addms
Construction Supenisor(CSL)
�, (� ,r� - �ren+e umbeEspuanon Date
er Typ Z b%iuw)
C-
T i U Unrestricte u t 3,000 Cw FiR Restricted IA d Dwellin_ �� N Masonry(WyRCResid ial Roc fin CovennI W S Re meal Window and Siding
SF Oesulcmial Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address Expiration Date f
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 2SC(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 Affdavit Attached? Yes.......... 0 No........... 0
SECTION 7a: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.
Signature of Owner Date
SECTION 76:OWNER'OR AUTHORIZED AGENT DECLARATION
1 ,as Owner or Authorized Agent hereby declare
that the statem
nts and information on the foregoing application are true and accurate, to the best of my knowledge and
6!r- C��
i/nt Name
C' �-/�S6Oi�'gnature of Oner w Authorized Agent Date
Si txd under e sins and penalties ofperjury)
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 W 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 110.R6 and 110.RS, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/arics,decks or porch)
Gross living area(Sq. R.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half baths
Tvpe of healing system Number of decks/ porches
Ty pe of cooling system Enclosed Open
3 "Total Project Square Footage"may he substituted for 'Total Project Cost"
CITY OF SMY—NI
PUBLIC PROPERTY
DEPARTMENT
NAVOa I-VWAYYNGWW"MZT 9 SALAK,y,ASMG&SaTi70t9'0
rVA.9"S-715-9s9S 9 V%X 9' W64
HOMEOWNER LICENSE EXEMPTION
Pies" "I
' pate m5 /
v by v
Job Location
Home Owns Address
Home Owner Telephone 471' S'T 7�� �� v✓/
Presort Mailing;Address
The current exemption of"Homeowm a was extended to include o ccupied
dual for
dwellings of two Unite or less and to allow such homeowners to engage an
indivhire who does not possess a license,provided that the owner seta era supervisor.
DEFINITION OF HOMEOWNER
Person(+) who owns a parcel of land on which hdshe resides or intends to reside, on
which there is, or is intended to be, a one or MG family,dwellin& attached or detached
structures accessory to such use and/or farm structures. A person who constructs more
than Otte home in a two year period shall not be considered a homeowner. Such
homeowner"shall submit to the Building O®cial,on a form acceptable to the Building
Official, that hdshe 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 "homeowned'certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/shewill comply with said procedure uirementL /
HOMEOWNERS SIGNATURE t/
APPROVAL OF BUILDING [NSPECTOR
See other side for state code
CITY OF SALEM
\ PUBLIC PROPRERTY
DEPARTMENT
S.\II'M. tit.Ni.\t iItat :Pr'.:
'I'Fl:47H-74i=)i9$ P.\x:979.740.7846
Construction Debris Disposal Affldavit
(required lur all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit t1 _ - _ 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
l l 1. S 150A.
The debris will be transported by:
Iname of hauled
The debris will be disposed of in
_.- (it neul aciity)
(address of Ncility)
.i ore of permit applicant
date