11 SAVOY RD - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
11Nf11 �' !I Massachusetts State Building Code, 780 CMR, 7"eJiZDolish
OF SALEM
Revised Jammry
Building Permit Application To Construct,Repair, Renovate Oa 1. 2008
One-or Tivo-Family Dwelling
This Secti ' For Official Use Only,
Building Permit Num Date Applied: Q 0
Signature:
6uiIdii3gC`un�miss(oncq tbfof Buildings- Date
SECTION 1:SITE INFORMATION
.1 Pro erty Address: V 1.2 Assessors Map& Parcel Numbers
Q JOV ram\
1.I a Is1.l a is this d street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
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? Municipal❑ On site disposal system ❑
Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
.1 Ownert of Rg�ord: /7TAd ..
Mary 1 \fc�ne 11 Sauoy 'Rcl
Name(Prin) ss for Service:z6i) aQt ¢ ecct`r �) 8. - 6�10 - 6 goySignature es5/u,/� ar L. '6 rnv_ relephone 7 pq-Og 5 9
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work2:f1'jrMC(-t +I, no1'e'+ )et.nroL* dt000al daor' con necHnothe
3.o-p ar thrn&n t'T 17oor nerds +0 he rr moucd a o d 'null tile op n '
r
o k Un11'(�j
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S/ 30 0_ 0 Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL-Holder List CSL Type(see below)
f.Pe Description
Address U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 FamilyDwelling
Signature M Mason Only
RC Residential Roofing Covering
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Burning A liance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address Expiration Date
Signature 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..........O No...........0
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.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
,y L. one
I, Z�• / omClA P �Cu N 25y<z e a{ �Gr� ,as Owner or Authorized Agent hereby declare
that t e statements and information on the foregoing application are true and accurate,to the best of my knowledge and
be If.
� �len �lJ Lenart e ecw o{ eS19-4-e o� (na--V L . V1
Pri e
es It 6 / f7 r 2 010
Signature of Owner or Authorized Agent gnarl L. ,Irn2 Date
(Signed under the Eams and penalties of perjury)
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&of have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"
'A CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
I'.II% M111 "Nlr.'I I
1'FI:v%1.7J49j9S �I'.\s:`%7Y7JS'1;N6
Construction Debris Disposal AMdavit
(required liar all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5
Debris,and the provisions of MGL c 40, S 54;
Building Permit H 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 MGL c
111. S 150A.
The debris will be transported by-
mama of hauler)
The debris will be disposed or in :
(11M of acf I Ity
IaddmN of I�rlhly) '/ /� Q y
V .Isnalurc of Iwrmit•pphc nt R i, L, �y f n 'C
date
Ichu•dl.:K
CITY OF S.ULE.NI
PUBLIC PROPERTY
DEPARTMENT
K1f0la{ir^�'�'•'w� I
- Wrae t3p�vwu�w,oMR.Ear�sKr�tN,.a�oasn,sot�'o
TIL rs-745•9s"•F.kL rs.74&964
HOMEOWNER LICENSE EXEMPTION
Plea"Prime
Date r� l t I
Job Location I Savov `S2
Home Owner Address 11 zo-u �)/ ✓�
HomsOa�narTelephonej�� -t4xt - quo - 686y i, �-1#8—`�4U-o`rs9
Present Mailing Address tt Sa,jov t?d M A o 1 q -7-6
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 who 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 belshe 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 wort 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE JV
-Qye est^ c 92cLry L. Byrne-' 7
APPROVAL OF BUILDNG NSPECTOR V
See other side for state code