16 SCOTIA ST - BUILDING INSPECTION 2� cK sg s
The Commonwealth of Massachusetts RECEIVED CITY OF
Board of Building Regulations and KrQsj IDNAL SERVICES SALEM
Massachusetts State Building Code, 780 CMR Revised,Nur 2011
Building Permit Application To Construct, Repair, RcM}a#*LbAmtaAh8 8
1 One-or Tivo-FamY il Dwelling
N
_ This Section For Official Use Only
Building Permit Number: 'Date App l3 Is
�
Signature
Date
tint Name). gn
' DuiiJin Otlicial(P_ ) _n g
SECTION t:SITE INFORNIATION.
( 1.1 Property,address 1.2 Assessors hlap&Parcel Numbers
16 C"
Number
1_�nI street? es X no Map Number Parcel
la Is this an accepted I. P Y —
1.3 'Zoning Information: 1.4 Property Dimensions:
"Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yams Rear Yard
Required Provided Required Provided Required Provided
S , 19 5;l S 161
1.6 Water Supply:(M.G.i.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 yes13
SECTION2: PROPERTY OWNERSHIP!`
2.1 O,�wn (`rofRe�o�i� { ` er Ulg70
13- Y � IZJ<7�f1L-&r
�me(Print) City,State,ZIP
0 le
No.and Street Telephone Email Address
SEL
3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
Eu
E!0
EBuilding❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
❑ Number of Units_ Other G-Specify: S
Brief Description of Proposed Work': a. i O_ aCkS
X./.)-/
SECTION 4: ESTIrNATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building S Sra.00 - 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Costa(Item 6)x multiplier x
3. Plumbing S 2'P Qther Fees: S
4.Mechanical (hIVAC) S — List:
5.Mechanical (Fire S Total All Fees:S
Suppression)
Check No._Check Amount: Cash Amount:_
G.Total Project Cast: S 4710-C70 - ❑Paid in Full ❑Outstanding Balance Due:
f5AE7�Tyf23
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name ul'CS1.Holder' - 44 List CSL'rype(see below)
No. and Street Type'. - Description .
U I Unrestricted(Buildings up to 35,000 cu.It.
R Restricted l&2 FamilyDwelling
City/rown,State,ZIP M Maso
RC Roolin Covering
WS Window and Sidinx
SF Solid Fuel Burning Appliances
Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
IIIC Company Name or HIC Registrant Name
No.and Street - Email address
City/Town, State ZIP Tele hone
SECTION 6t 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 Isluance of the building permit.
Signed Affidavit Attached? Yes ..........I] No...........❑
SECTION 7o:OWNER AUTHORIZATION.TO BE COMPLETED.WHEN
OWNER'S AGENT OR 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 nam ,I her by attest under the pains and penalties of perjury that all of the information
cont.' plic io is r and accurate to the best of my knowledge and understanding.
Prh er'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 Lint have access to the arbitration
program or guaranty fund under M.G.L.c. 1 d2A.Other important information on the HIC Program can be found at
%vww mass.cov'oca Information on the Construction Supervisor License can be found at www.nmss.•tov;'Jns _
2. When substantial work is planned,provide the information below:
Total tloor area(sq. ft.) .(including garage, finished basementlattics,decks or porch)
Gross living area(sq. 11.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
rype of cooling system Enclosed Open
3. `Total Project Square Footage"may be substituted for"Total Project Cost"
QTY OF SALEM, MASSACHUSETTS
BUILDING DEPARTMENT
120 WASHINGTON STREET,3 RDFLooR
TEL. (978) 745-9595
FAX(978)740-9846
KINIBERLEY DRISCOLL
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMAIISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date y d I- 15
Job Location 1,6 /�// ' 1
Home Owner Address 16 SC1j+1C(_ 5t
/Present Mailing Address b �J_10 5�
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 requir a and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR
QTY OF SALEM, MASSAMUSE7TS
y 1 } BUILDING DEPARTMENT
110 WAsmNGTONSTREET,3'DFLOOR
T1;L.(978)745-9595
KIIvIDERLEYDRISCOLL FAX(978)740.9846
MAYOR THomrAs ST.PIERRE
DmECI'oR OF PUBLICPROPERTY/BLIILDING ODMhMIOMR
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 c40, 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 deposit 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)
S ature of applicant
Date
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