10 SABLE RD WEST - BUILDING INSPECTION (a 2 4 — 1 4 'J I s>s- R'r.
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4�' The Commonwealth of Nlassachusetts INSFILGI $ RVICES
Board of Building Regulations and Standards CI"fY OF
Massachusetts State Buildin Code, 780 CNI �, hiMar
pf g �IIY Ff8 ?? i8t•i.��.tlur ton
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Fancily Dwelling
This Section For Official Use Only
Building Permit Number. ate Applied: Z
Building Official(Print N:une). Signature Date
SECTION I:SITE INFORMATION
1.1 rypert Address: /£f� 1.2 Assessors Map 3r Parcel Numbers
I.la Is this an accepted street?yes`-✓--'- no Map Number Parcel Number
1.3 Zoning Information: I rrop rty Dimensions:
Zoning District Propose)Use Lot Area(sy tl) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yams 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:
/ Zone: _ Outside Flood Zo Munici of60 On site disposals stem ❑
Public L9' Private❑ Check if esl p y
SECTION2: PROPERTY OWNERSHIP'
2.hOwnerI of Record: n
/J/-/6'/� T ✓f�/2rCC / "J�
I��nte(Print), City,State,ZIP
A _J a �J 3 f 970A ;7o<'J-yL
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building Erf Owner-Occupied Repairs(s) ❑ Alteration(s) e Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ I Other ❑ Specify,
Brief Des/cription of P posc�,Work':
r c c a . erJi
p,L r• c'TlNN, 2.0om-� ►Ja S-i--.VC,TUCzf�. C.rl.F�cN<a
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building $ �Q'Q 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ../p ❑Total Project Case(Item 6)x multiplier x
.S
3. Plumbing V O v 2. Other Fees: S
d. Mechanical (FIVAC) S List:
5. >lechanic:d (Fire S rotas All Fees:S .
Suppression)
Check No._Check Amount: Cash Annnmt:
6. Total Project Cost: .S �V0 d 13 Paid in Full 11 Outstanding Balance Due:
,
�ECT16N 5: CONSTRUCTION SERVICES
5.1 Cuustru,},tion Supervisor License(4SL)
License Number E.xpimtionData
Name of CSL Holder List CSL'rype(see below)
Type Description
No. and Strut
U Unrestricted(Buildings ill to 35,000 cu. ttJ
R Restricted U2 Family Dwelling
C'ity1fown,Slate,ZIP NI Masonry
RC Roo ling Covering
WS Window and Siding
SF Solid Fuel Burning Appliances r
I Insulation
Telephone Email address D Demolition
5.2 Registered Home improvement Contractor(HIC)
HIC Registration Number Expiration Date
IIIC Company Name or HIC Registrant Name
No. ,aid Street Email address
t City/Town, State ZIP 'role hone
SECTION 6:WORKERS'CONIPENSATION 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 Is�uance of the building permit.
Signed Affidavit Attached? Yes ..........13 No...........0
SECTION 7a:OWNER AUTI(ORIZATION.TO BE COMPLETED WHEN. i
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
[,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's N:une(Electronic Signature) Date
SECTION 7b:OWNEW 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. .
i
Print Owner'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
(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 call be found at
www.masS.aov'oca Information on the Construction Supervisor License can be found at% .naSir ovAIo
2. When substantial work is planned,provide the information below:
Total Iloor area(sq. R.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. If.) Habitable room count
Number of fireplaces" Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating systeln Number of decks/porches
Typeorcoolingsystem Enclosed Open--
1. "focal Project Square Footage"may be substinited for Total Project Cost"
CITY OF SALEM, MASSACHUSETTS
h . BUILDING DEPARTNIENT
I
120 WASHINGTON STREET,3" FLOOR
\ � TEL. (978) 745-9595
KIMBERLEY DRISCOLL FAX(978) 740-9846
MAYOR TY-IONIAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date.Z
Job Location �� 4 >/ �� e r.j r
Home Owner Address J- _r
Present Mailing Address_- / ,,
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 de /
iC
APPROVAL OF BUILDING INSPECTOR
CITY OF siuL E,lIi, XSSACHUSETTS
BU=LNG DEP.AHTNZNT
110 WASHNGTON STREET,Jr°FLOOR
'. ic , " Ill. (978) 745-9595
F.tx(978) 740-9844
Kl\tBEIiLcY DR.ISCOLL
�L1YOIl T HOAAS ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/8UILDLN<;COJOIISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section l l I.5
Debris, and the provisions of NIGL c 40, S 54;
Building Permit it is issued with the condition that the debris resulting from
this work shall be S I SOA. disposed of in a properly licensed waste disposal facility as defined by t�IGL c
The debris will be transported by:
y
(name ofhauler)
The debris will be disposed of in
(nnrne of tacdily)
Cures �/
/\)--
(addres.5 or lacoity)
i
Ignatur fpermitappfieant
,i.tle