12 SILVER ST - BUILDING INSPECTION I'he C'uminon weal lh of Massachusetts —
�� Board of Building Regulations and Standards CI"I'Y OF
t)' i Massachusetts State Building Code, 730 C NIR SALLI
dl) Building Permit Application To Construct, Repair, Renovate Or Demolish u
One-or Two-Funtih'Drellin.K
This Section For Offi•'al Use Oul
Building Permit Number: D e Applied: _
Budding 011mil(Print N;unc)
Signature Uute
SECTION 1:SITE INFORMATION
IA ?-Proper Address: 1.2 Assessor r
M1iap& Parcel Numbers
� l )er C-� -
I.I a Is this an accepted street. yes no Map Nunther Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
liming Dibincl Proposed U c Lot Area(sy 11) Fmmage 111)
1.3 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required q Provided Required Provided
1.6 Water Supply:(M.G.I.c.40,§Sq) 1.7 Fload Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: — Outside Flood Zone?
Check iFes❑ Municipal ❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP,
2.1 Own er`of ecord:
rk Salek4 Ma ta�a
Nana(Print) C ay.Slate,l.IP O
ern �y 83�1 ►�� Q SA�1 rca�No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition Accessory Bldg. ❑ I Number of Units_ I Other ❑ .Specify:
Brief Description of Proposed Work't:
_Llul'(1 I X f�� �oOT CJ1P (tM rtnnn O .>,
v
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and.Materials) Offlcial Use Only
I. Building $ I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical s ❑Standard City/Tovn Application Fee
❑Total Project Cost'them 6)x multiplier _ _ x
7, I'IumM°g s 2, Other Fees: $ ',.�p1 — ---
4. Mcch;ulical (ll\':W) S List:_ \ _ -_
\lechanical (Fire s --
Su�nession) 'total :\Il Fces: S
� e Total Project Cost: S ('heck No. —_—('heck:\mount: -
S /Q ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONS'I'RUCI'ION SF.RVICES
5.1 Construction Supervisor License(C'SL)
License Number--' -- P\pir iiou Dale
Nanc of CSI. I loldcr --
- List CSI,1)pc(see hclawl
.-------- .I.s Pe Description
No. and Street
U Unrcsiricled(Building,up it) 15,UI10eu. Il.l
_ _ R Restricted Lr2 laniil Decllin
Citci rolls.Slate.LIP ------- M1I Nlasonry
RC Riwtin C'averin
_- W'S Window and Siding
SF Solid Fucl llurning Applialces
1 Insulation
I'cle hone Finail address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
IIIC Registration Number INPiration Date
i IIC Compan) Nanic or IIIC Registrant Name
No.and Street_ Email address
City/Town,State,ZIP rele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G,L c. 152.4 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 .......... ❑ No........... ❑
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 0mief s Name(Electri nic Signature) Dale
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(he best of my knowledge and understanding.
Prim Usi oar's or AuthoriicJ,\gene's N;unc I lilcctronic Signature) Date
NO FLS:
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 no have access to the arbitration
program or guaranty fund under M.G.L.c. I12A.Other important information on the HIC Program can be found at
lils,l m.t,, �c,l information on the Construction Supervisor License can be Pound at il.)slk.mas; gip, Ip.
2. When substantial work is planned, provide the information below:
Total fluor area I sq. R.) _ 1 including garage, finished basement allies.decks or porch)
truss living area(sq. Il.) _ Habitable room count
\umber of fireplaces._ ..._ Number of bedrooms
Number of bathrooms -._ . -- —._ . . Number ofhalf haths
I)pc ul healing s)stent .. .. . - -- \umber ol'decks, porches _
I)lie cif coolllla SN Stein ..,_ -. - Fllchiscd _.. .. - Open
1, "focal Project Square Footage"nut) be substituted t'or"Total Project Cost"
CITY OF S.XI.E%v1
PUBLIC PROPERTY
DEPARTI[ENT
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tit+-8-715.+s"+F.%s+'8.71696e
HOMEOWNER LICLNSE EXEMPTION
P1es" Pti1111
Date
Job Loeattan 12 S 1 1 Uf t S4
Home Owner Address l Z r
Home Owase Telephone 9 7SR 7 - 7
Prcssd Maillnst Address I Z rye
The current exemption of"Homeowner"was extended to include owner-occupied
dwellings of two Unite or leis and to allow such homeowner to engage an individual for
him who.does not possess a lice nse4 provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Persons)who owns a parcel of land on which he/she resides or intends to reside,on
which there ia, 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
.vil]comply with said procedures and requirements.
HOMEOWNERS SIGNATURE K sit X�Iol
APPROVAL OF BUILDING INSPECTOR
See other side for state code