2 SCENIC PL - BUILDING INSPECTION (2) 4 o C) 14
Cr,\<;1A
The Commonwealth of Massachusetts
� Board of Building Regulations and Standards CITY OF
d47 Massachusetts State Building Code, 780 CMR SALEN
Mar
Revisedtl:L(nr 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Divelling
" This Section For Official nly: -
BuildingPermitNumber: Date plied: qey P.
Building.Otlicial(Print Name):. Signature Date
SECTION I":•SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
a; ��nic, Plo,cs�
I.1a 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 R) Frontage(It)
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 ifyesO
SECTION26 PROPERTY OWNERSHIP'
2.1 Owner of Record: 11
L-tr1Q9 Get YW(1 Sct� M �tc)C)
hme(Print) City,State,ZIP
2 Sce Y11 c P lal csz °�8-�3b-C9 I t rlaa� bos}� ab,
No.and Street Telephone Email Address
SECTION.3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ 1 Existing Building Owner-Occupied%Vf I Repairs(s) Cl Alterntion(s) ❑ Addition $1
Demolition ❑ 1 Other ❑ Specify:
Brief Description of Proposed Work': 1 A5+ t\ CVj.jQ:J::: IIt Q KSSP
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building S 1, Building Permit Fee:$ Indicate how fee is determined:
�. Electrical $ ❑Standard City/Town Application Fee"
❑Total Project Cost'(Item 6)-x.multiplier x _
3. Plumbing $ 3-a C30 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount
6. Total Project Cost $ ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5; CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL(folder
List CSL'fype(see below)
No. and Street Type,, Description. -
U Unrestricted(Buildings LIP to 35,000 cu. RJ
R Restricted 1&2 Family Dwelling
City/l'own,State,ZIP M Nfisonry
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)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.,152.§ 25C(�)
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 FORBUILDING PERMIT
1, as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work au rued 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 this application is true and accurate to the best of my knowledge and understanding.
Lanclg GQg)non q ) L4 3
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(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program can be found at
www.mass.�Iov:'oca Information on the Construction Supervisor License can be found at w kv, nmssnqoe:l(IRS
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 S.1L. m
PUBLIC PROPERTY
DEPARTMENT
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HONIEOWNER LICLNSB EXE.tiIPTIO,V
Please prime
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lob Laeadora a 2 Yl is p1gcJ�
Home Ownm Addeear r
Home Owner Telepboam
Presemt Mathis g Address 9a Sn o
The current exemption of"Homeowners"was extended to include owner-occupied
dwenings of two Unite or less and to snow such hmeowums to engagr set individual for
hire who dam not possess a license provided that the owner seta err supetttvisos:
DERNMON OF HOMEOWNER
Person(s) *be owns a pmsA offend on which hdsM redder or Intends to resider on
which them ter or Is Intended to be a ooe or two lltmily dwelling attached or detached
Structures accessory to.such use and/or(arm aMucturea A person who comuvcts more
than one home its a two year period share not be considmad a homeowner. Such
"hameownd'shali submit to the Building Odlei4 on a form acceptable to the Building
OfAciaL that hatshe be responsible for all Such wort performed under the Building
Permit
Ths undersigned "homeowner"auumes responsibility for compliance with the State
Building Code and other applicable by flaws and reettladons.
as undenigned "homeowner"certiAa that he/she undentands the City of Salem
Building Department minimum inspection procedures and requirements and that hdshe
mill comply with Said procedures and requirements. .
HOMED WNERS S[GNATL-RB
.1PPR0VAL OF 3U1LD/VG LVSPECTOR
Sce other Side far stale cads
CITY OF S.U.E.M. XWSACHUSETTS
BUILDL\G DEPART\tEINT
• 120 WASHNGTON STREET, 3" FLOOR
TEL (979) 745-9595
Fia(978) 740-9846
}OAtgFRi RY DRISCOIS
MAYORTHOStAs ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDNG CON06IISSIONER
Construction Debris Disposal Affidavit
(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 c 40, S 54;
Building Permit# 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:
(name of hauler)
The debris will be disposed of in :
(name of facility)
(address of facility)
No"
of plc it applicant
date
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