34 SABLE RD - BUILDING INSPECTION --7zi
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The Commonwealth of Massachusetts RECEIV O 71,
Board of Building Regulations and StandardSINSPECTIONAL SER�Massachusetts State Building Code, 730 CMR Revisedblur 2011
olOf�llA12111 P 11: 4Z
Building Permit Application To Construct, Repair, Renovate ,
One-or Tivo-Family Dlvelling
This Section For Official Use Onl
ly
Building Permit Number: Date A 3_ mac_/y
Uuilding Ol'ticiul(Print N;une). Signature Dote
SECTION 1:SITE INFORMATION'
LJ]I upper Address'� �� =Kt—,p—Nm3b,0,'
s Map Sc Parcel Numbers
I.l a Is this an accepted street?yes no Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Lot tt Frontage It
Zoning District Proposed Use ( 9 ) g O
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.&Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Cluck if es❑
SECTION2: PROPERTY OWNERSHIP''
2.1 Owner of Record o
A.v17��w �'.ic2�v�� Sr}l�M,/ylA, �i970
�ine(Print) City,Slate,ZIP
31Z/S�i e — 7B/ z/v�7�zy
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied)q I Repairs(s) ❑ I Altemti(3n(s);�, Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work': Lr9Gt yTG/1 C A±� Tf �✓��
SECTION a: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials)
I. Building S gqv e'J I, Building Permit Fee:S Indicate how fee is determined:
❑Standard Cityfruwn Application Fee
2. Electrical S .?-C'o O ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
I.Mechanical (HVAC) S List:
5. \Iech:mie:d (Fire S rutal All Fees:S
Su ressioll)
Check No._Check Antounl: Cash Amount:_
El rotal PII Paid in Full 0 Outstanding Balance Due:
ci.Tutul nect Cult ov Cl
SECTION 5: CONSTRucTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number E.epiritiun Date
NanicufCSL'lluldcr lLl
List CSL'rype(see below)
Type Description
No. and Street
U Unrestricted(Buildings tip to 35,000 cu. IL) i
it Restricted 1&2 FamilyDwelling
City/I'uwn,State,ZIP M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation �
'Nle hona Email address U Demolition
5.2 Registered Home Improvement Contractor(HIC)
11IC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No. and Street Email address
cityrrown,State ZIP rele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(VI.G.L.c.152.1 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
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
containe it its it tion ' ue and accurate to the best of my knowledge and understanding.
Print er'�or %oth Agcnt's Name(Electrunic 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(111C)Program),will trot have access to the arbitration
program or guaranty rund under,bl.G.L.c. I42A.Other important information on the HIC Program can be found at
i�ww.mass. •oL y:OC;i Inrormatiun on the Construction Supervisor License can be found at nww.niass. •ov!JL
2. When substantial work is planned,provide the intonnation below:
Total door area(sq. It.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. 11.) Habitable room count
Number of fireplaces, Numberofbedrooms —:z
Numberofbathrooms / Number of half/baths
type of heating system Hrl ,7— wATt4 Number of decks/porches i
fypc otcooling system unclosed Open_
1. "Ibial Project Square Footage"may be substituted tar 'Fotul Project Cost"
CITY OF SALEM, MA.SSAGTI[JSETTS
1 frj BUILDING DEPARTMENT
vp p 120 WASHINGTON STREET,YD FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KIMBERLEY DRISCOLL
MAYOR TY-IOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT: L/
Date 3 //
Job Location
Home Owner Address 3y
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
APPROVAL OF BUILDING INSPECTOR +.
�hvr
CITY OF S.0 F-,Nf, NL- SSACHUSETTS
BULMLNG DEPARM&NT
130 WASIANGTON STREET Ya FL
v, TEL (978) 745-9595 ooR
F.*,v(978) 74OL9845
Kt\ SE1tLEY DtiISCOLL
&L.1Yoli Tr-to.ws ST.P[ERAa
DIRECTOR OF PUBLIC PROPERTY/BCUML11G COMMISSIONER
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 1 l 1.5
Debris, curd the provisions of rbiGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by bIGL c
l 11, S I50A.
l'hc debris will be transported by:
ti
y tv iK �yivg �s2j ✓✓ 7 `
(name of hauler)
The debris will be disposed of in W / l
— (narne of facility)
(address of tacilily)
signature ofpermit a --
daft