29 SABLE RD - BUILDING INSPECTION (2) � ZS04
The Commonwealth of Massachusetts CITY OF
C11TV
Board of Building Regulations and Standard VED SALEM7 . tState Buildin Y 'Y,•Massachusetts g viseJalur2011��'S�tL��li3�� SERVICES
Building Permit Application To Construct, Repair, Renovate Or Demolish a
OOne-or Two-Family Div ', _
This Section For OffC-N se of .
Building Permit Number: Date.A lied:
Building Otticial(Print Name). Signature Date
�1 SECTION t:SITE INFOR,NIAT101W
I 1 L 1 Property Addres,+: 1.2 Assessors blap& Parcel Numbers
!t_ z 5,
I.1 a Is this an accepted street?yes_ no_ M1fap Nwnber Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
"Zoning District Proposed Use Lot Area(sy It) Frontage(It)
1.5 Building Setbacks(R)
Front Yard Side Yams Rear Yard
Reyuin:J Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.d0,§Sd) 1.7 Flood Zone information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑
SECTION2: PROPERTY OWNERSHIP!'
2.1 Owner t of Record:
7zoae, +3a S'� /�� Mcir d/g 70
thme(Print) / City,State,ZIP -{-
2.c1 57 l? rg 7'/S77/3
No-1 ul Street Telephone _ I Email Addres
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
I
w Construction O Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑molition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Descriytion of Propose 1V
/ X /Z.� S
SECTION J: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Itcm Labor and Materials -
1. Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(item 6)x multiplier x
3. Plumbing $ 2`P Qther Fees:
4.Mccitmtical (HVAQ S List:
5.:\lechanical (Fire S " otal All Fees:$
Suppression)
Check No._Check Amount: Cash Amount:
6.Total Project Cost-. s 3 y Oo ❑Paid in Full ❑Outstanding Balance Due:
MP�\��ro IoIt3
SECTION 5: CONSTRUCTION SERVICES
5.1 Coustructimt Supervisor License(CSL)
License Number Expiration Date
Name of CSL flolder
List CSL'rype(see below)
No.;mJ Street Type Description
. . -
U Unrestricted(Buildings tip to 35,000 cu. R.
R Restricted I&2 Family Dwelling
Cityfrown,State,ZIP M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
1-11C Registration Number Expiration Date
I IIC Company Name or HIC Registrant Name
No.and Street - Email address
Cityrrown,State ZIP Telephone
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 Isivance 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
1,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 Name(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 andaccurate to the best of my knowledge and understanding.
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 1I.G.L.c. I42A.Other important information on the HIC Program can be found at
www max,a:ov:'oc:l Information on the Construction Supervisor License can be(found at www.masssov'Jus .
2. When substantial work is planned,provide the information below:
"rota) fluor area(sq. ft.) 4 .(including garage, finished basement/attics,decks or porch)
Gross living area(sq. ft.) - Habitable room count
Number or 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
.1. Total Project Square Footage"may be substituted for"Total Project Cost"
• `° CITY OF SALEM, MASSAaiLTSETTS
BUILDING DEPARTMENT
l 120 WASFUNGTONSTREET,3ADFLOOR
m TEL. (978)745-9595
KIMBERLEY DRISCOLL FAX(978)740-9846
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONI IISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date /0— o7-16_
Job Location Z 9 SA6�� �� .S'w/,2
Home Owner Address 2- ' SAjI-- ;2fS,�
Present Mailing Address_ Z9 Sn Alp- �J.
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. /J
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR