18 SAVOY RD - BUILDING INSPECTION Fhe Commonwealth of Massachusetts
i OF
Board of Building Regulations and Standards SAL M
Massachusetts State Building Code, 780 CMR S`'Lbu Re riled I.1 far/ur 201!
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling
This Section For Offici 1 Use Only
Building Permit Number: Date, pp lied: qd/l/
Building 011icial(Print Name) Signature pate
SECTION 1:SITE INFORMATION
1A Property Address: 1.2 Assessors Map& reel Numbers
I.Ia Is this an accepted street?yes no Map Number Parcel Number
1,3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) 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.1.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public' Private❑ Zone:AIA Outside Flood Zone?
Check if yes❑ Municipal J(On site disposal system ❑
i SECTION 2: PROPERTY OWNERSHIP'
u'( 2.1 Owner'of Record;
M,aeGag4r �(ee� t Jt lke i S SA.em ass S. o i5�o
N:une(Print City,Slate,ZIP
i g 5hf"o K /ZD- 9W ;7 yJ6d
No.and 9 Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building k Owner-Occupied Repairs(s) Alteration(s),0 Addition ❑
Demolition Accessory Bldg.❑ I Number of Units-1 I Other ❑ Specify:
Brief Description of Proposed Work': inn✓C pY� 'f�/� ��, G �
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building S 00 0 I. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
0 v ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S d o O 2. Other Fees: S
4. Mechanical (II\',\C) S m List:5. ,Mechanical (Fire 3 _
Su ression) O Fund All Fees: S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S -- --- -
Z �0 O ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(C'SL)
Name of CSI. I IulJcr —_—__—
License Number lispiruion Dale
List CSI-i)yc(see below)
No.and Street Type Description
t1 l Inrestricted iffilildings up to 35,000 cu. It.)
R I Restricted 1&2 Family IAvellin
City/I'm%n,State,ZIP M Mason
ry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Icic hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC'Registration Number Expiration Date !
HIC Company Name or I IIC Registrant Name
No. and Street Email address
City/Town,State,ZIP rele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.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 .......... O No........... 13
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 this application is true and accurate to the best of my knowledge and understanding.
Print( %%ner's or Authorized Agent's Name Wlecnunic 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. 112A.Other important information on the HIC Program can be found at
t% mp . ;Ln nc) Information on the Construction Supervisor License can be found at g�y)g�ua .gm_'Ji»
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 halfbaths
--------------------
1}pe of hc:uing system Number of decks,porches_
------------- --- -- --------------
1)peofcoolingsystem Enclosed _ Open __-- __--
3. "Total Project Square Footage-may be substituted for"focal Project Cost"
CITY OF S.U.E.vI
PUBLIC PROPERTY
DEPART'N1EN'T
woen"04=%A,
V'•ro• i ao v.ou�w,oM srusr•sNas�Vnaeowssrn Otf-t+
rtL•-ar+s-ss•s•t..x 976.74&964
HOMEOWNER LICENSE EXE.MMON
Pies" PtrInt
Dap
Job Locadas
Home Owner Address ,V- C
Home Owner Telephone 2�76 G
Presort Mailing Address y
no current esemptioa of"Homeowner"was extended to include ownw-occupied
dwellings of two Units or less and to allow such homeowners to engage an individual for
hire who does not poaess a license,provided that the owner,acts as supervisor.
DERNMON OF HOMEOWNER
Person(s) who owns a parcel of land on which Wsbe resides or intends to resider on
which there is, or is intended to be, a one or two family dwelling attached or detached
structures accessory to such uss and/or farm sttucturee. 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
Ofticial, 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 reguladons.
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.
n
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side far state code
CITY OF SM.&M, NLASS.ICiiUSETTS
9LILDLYG DEP.1IMONT
110 W.UHLNGTON STREET, J"FLOOR
T*EL (978) 745.9595
PU(978) 740.9W
KINMERLEY DRLSCOLL
MAYOR Tkouu ST.Pmllgs
D(RECTOIL Of PUBLIC PROPERTY/11LI LNG CONNISSIONER
e Construction Debris Disposal Afildavit
(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 a 40, S 54;
Building Permit Al is issued with the condition that the debris resulting from
this work shall be disposed of--in properly licensed waste disposal facility as defined by MGL c
I 11, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in :
�UIM
(name of facility)
(address of facility)
eiynamre of permit applicant
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