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8 SALT WALL LN - BUILDING INSPECTION c� 155 Lj v " ILI The Commonwealth of Massachusetts CITY OF Board of Building Regulations and Standards SALEM r Massachusetts State Building Code, 780 CMR Revised Mar 2011 �V Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use On y n Building Permit Number: ' ate Applied: „(\ Building Official Mint Name) , '� ,"• _ Signature " SECTION:L`SITE INFORMATION ' 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers. Va Nl Ma Number Parcel Number r l.la Is this an accepted street?yes_ no P - 1.3 Zoning Information: 1.4 Property Dimensions: D � - G Zoning District Proposed Use Lot Area(sq it) Frontage(ft) tom,...,. 1.5 Building Setbacks(it) Pc� `•^' Front Yard Side Yards Rem 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 Zone? Public Cl Private❑ Check if yes❑ Municipal❑ On site disposal system ❑ - SECTION 2: PROPERTY OWNERSHIP[ 2.1 Owner[of Record /,� —y/� r�14u� 0/J ! Sct (Pvni // r/ 7 Name(Print) City,State,ZIP S�1 //- �1 � � s� rclb T/(rT No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WOW(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: Brief Description of ProposedWorV: uwab• 4>0%s i>.et v. VOat CoAmot lkcjj1r 3ns¢o+tw4 w;n!kows %e \ct W \V% M k GO, \ieycxc \ \xeu SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only. (Labor and Materials) 1. Building Permit Fee:$ Indicate how fee is determined: 1.Building $ +5 2.Electrical $ ❑Standard City/Town;Application Fee ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. OtherFees: $ - 4.Mechanical (HVAC) $ :List: 5.Mechanical (Fire $Su Total All Fees:$ Check No: Check Amount: . Cash Amount: 6.Total Project Cost: $ , �© ❑Paid in Full ❑Outstanding Balance Due: 4�0-f- G Lo.s t 1.)Gt O t=X r w —� CTH J rz s o z Frr t C4 r-)N)1_. To G.c- SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder List CSL Type(see below) No.and Street Type Description ' U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted 1&2 Family Dwelling City/rows,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances _ I Insulation v Tele'hone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HICGompany Name or HIC Registrant Name HIC Registration Number Expiration Date No.and Street Email address Ci")Town 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 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:OWNER'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 thiVon is true and accurate to the best of my knowledge and understanding. Prin[Owner's or Au�th rize�gent's Name(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 Home 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 wtivw.mass.sov,/oca Information on the Construction Supervisor License can be found at www.mass.eov/dp_s 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/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"Total Project Cost" CITY OF SALEM, MMSACHUSETTS BUILDING DEPARTMENT 120 WASFENGTON STREET,3" Rcm ' TEL. (978) 745-9595 FAX(978)740-9846 KIMBERLEY DRISCOLL MAYOR THomAS STTIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: Date Job Location U SC��Y��l \v\ le� A. Home Owner Address 56 {50. 4 `1\ Wt*l MR Present Mailing Address �t \\6- Y l DV ��q\h243, 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 5 APPROVAL OF BUILDING INSPECTOR Cr7y OF SALEg A ASSAaiusms B[EIAmDEPAimrm 120 WA9MYWWS7RPET,3RDROM Tkt.(978)745.9393 PAX(978)740.9846 Sl1vlBERLEYDRISQ7LL MAYOR 7)XUssSTJUM DIRECrCa aFmWCPRC)IPEM/BuLw,,oG aWuSS am Construction Debris Disposa/Afdavit (required for 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 coo,S 54; Building Permit g is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste deposit facility as defined by MGL c 111, S 150A. The debris will be transported by.- (name of hauler) The debris will be disposed of in: Q� (name of facility) (address of facility) Signature of applicant Date