11 SAVOY RD - BUILDING INSPECTION (2) Cs The Commonwealth of Massachusettsw
Board of Building Regulations and Stanry R CITY OF
I Massachusetts State Building C04et $
SALEM
Revised Mar 2011
Building Permit Application To Construct, RepAir, Renovate Or Q6,a emgli
One-or Two-Family Dweifuw Q,T. 1 3 A
This Section For Official Use Only
Building Permit Number. Da Applied:bo
'
i%Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address* 1.2 Assessors Map& Parcel Numbers
1 I I Scw 04 fm
L l a Is this an accepted street?yes_)K no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq fit) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards 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:
Public❑ Private❑ Zone: Outside Flood Zone?Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Jarnes 'R7LA iA -43a6in MA . OlcNq
Name(Print) City,S IZtetaCity,state,
l tyav Rd R7 - o Saft5t>- & r� hct{rrGrl.C�n
No.and Street I Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s)X Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Work': f Ye � O support
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
1. Building $ I. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost',(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
30 Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
— M fa t t i a l
—tJa1p5 1wSpetnotes ^
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/Town,State,ZIP M Mason
ry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
H
HIC Company Name or HIC Registrant Name IC Registration Number Expiration Date
No.and Street Email address
City/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
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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 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.
vvua� �� i / f I11,0
Print wner's or Aut crrized gent'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. 142A. Other important information on the HIC Program can be found at
www.mass.eov%oca Information on the Construction Supervisor License can be found at www.mass.eov/dns
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"
07YOPSAUA MAS'S'AQ-MI
B►KVMDareaaMr
IM We9AN&7V rSIMr YwFjoz
$>1�Ri8rIUMOML AAz"740.00
MAIM nXIMASSrJUM
Construction D -
eb r/s Disposes/Af�dovit
(required forall demolition and renovation wonky
In aeeordnoe wIM the sbth edhfon of the State&"W Code, 780CAML Se+cdw 111.S Deb!
and the WvWdmo of MGL ew S S4;BuOft p*n*B I IsAn ed with the
oonditlon dwthe debris msuloW from thls warkshaff be dt ad of in a pnoperN Boensed
waste dePwft fadrdYas defined by MGL c 111,S jr
The debris wig be transported by:
�meofhaulerj��
The debris will be disposed of in:
A
(name offadi ty)
(address of fadgty)
Signature of applicant
ate
a
CITY OF SALEM MASSAGiUSE M
BUILDINGDEPARTMENT
120WASHINGTONSTREET,3A Rom
TEL.(978)745-9595
K11V1BERLEYDRISCOLL FAX(978)740-9846
MAYOR THohw ST.PIERRE
DIRECTOR OFPUBLICPROPERTy/BLIIIDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT.
Date
Job Location_ (JQ y
Home Owner Address Stva !mil
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 SIGNATUR
APPROVAL OF BUILDING INSPECTOR