16 SCENIC AVE - BUILDING INSPECTION cl--
RECEIVED
INVECTIONAL SERVICESTheCommonwealthofMassachusetts CITY OF
Board of Building Regulations and Standards SALEM
I sachusetts State Building Code, 780 CMR Revised.Nur 2011
APA 15 A b� ��
I Building Permit Application To Construct, Repair, Renovate Or Demolish A
One-or Two-Family Dwelling
_ This Section For Official Use Only
^^ Inn Building Permit Number: D lieds
t�_I. S
Building OBfcial(Print Name). .-_ Sigma - D e
SECTION 1 SITE I FORMATION
I.1 Property Address: 1.2 Assessors Map&Parcel Numbers
\ (la SCC� IG f}Ve'
L I a Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Properly Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(It)
1.5 Building Setbacks(R)
Front Yard Side Yams Rear Yana
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? Municipal❑ On site disposal system ❑
Public❑ Private❑ — Check if es❑ P Po y
SECTION2! PROPERTY OWNERSHIP,
2.1 Ownerl of Record:
�/ DEz�I� wH,fE SALen.t MA 01q-)6
15me(Print) City,State,ZIP
16 S6 , )IC, AUE c116 Zto—SSOb c4twI,,i1. 93 yahad . CO
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ 1 Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other O Specify:
Brief Description of Proposed Work:ei�s}j wood t Slouc reed acrm i F+�
l� SECTION 4: ESTIbIATED CONSTRUCTION COSTS
Item Estimated Costs: Offieirl Use Only
Labor and Materials)
I. Building S I. Building Permit Fee:$ Indicate hose fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cosh(item 6)x multiplier x
3.Plumbing S P Qther Fees: S
4. Mechanical (11VAC) S List:
5.Mechanical (Fire S Total All roes:S
Su ression)
Check No._Check Amount: Cash Anwunt•._
6.Total Project Cost: S •Z 5 d D ❑Paid in Full ❑Outstanding Balance Due:
MA1tiro qjZ )
SECTION • CONS'rRUCrION SERVICES
5.
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL'fype(see below)
No.and Street Type - Description
U Unrestricted(Buildings tip-to 35,000 cu. 11.
R Restricted I&2 Family Dwelling
City/1'own,State,ZIP M Masortry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address I D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town, State ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L:c.152.¢25.0(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 Isluance of the building permit.
Signed Affidavit Attached? Yes ..........O No...........O
SECTION 7a:OWNER AUTHORIZATION.TO BE COMPLETED W HEN!
OWNER'S AGENT Olt CONTRACTOR APPLIES FOR BUILDING PERMIT`
1,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 Name(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
contained in tion is true and accurate to the best of my knowledge and understanding.
X U this app ca� 0yfby-115-
Print Owner's or Authorized Agent'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(111C) Program),will nol 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 un:'oat Information on the Construction Supervisor License can be round at www.ntass.��o��'Jns .
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) 9 ,(including garage,finished basementlattics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/batlis
'type of heating system Number of decks/porches
Type of cooling system Enclosed Open
). `Twnl Project Square Footage"may be substituted for"'rutal Project Cost"
CITY OF SALEM, MASSACHUSETTS
..
BUILDING DEPARTMENT
120 WASHINGTON STREET,3 FLOOR
TEL. (978) 745-9595
FAX(978)740-9846
KINMERLEY DRISCOLL
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date Dyl is- r \
Job Location 1b SCC,- lc A-6 SAL-em , /q c( S'] A
Home Owner Address IC Y(_el, tc Rye CnCtm 6t(?o
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 f
APPROVAL OF BUILDING INSPECTOR