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1 STORY RD - BUILDING INSPECTION � �3- I �-� 2� � �25 � 3io ;;a "fhe Commomvealth of Mass�chusettsRECEIVED - 's• '�• Board of tiuilding Regulations an��gyhfdgNAl SERVICES CITY OF ��y � � �,�� 'j(,/,� Massachusetts State Quilding Code, 780 CMR SALEM "��;.:' Revised Mar 20/l Duilding Pernii[Application 1'o Construct, Repair,�ao,��(br�e�i o��fi�3 Oi�e-or 7ivo-Fcunily Drve!lrng This Section For Official Use Only � Building Pemiit Number: Date Applied: � � n �. / � /g � 13uilding 017icial(Print Name) SignaWre � Date SECTION I:SI'PE INFORMA'PION LI Property AJdress: � �r L2 Assessors i�tap 3c Parcei Vumbers / S I v/2 � RGa4 L I a is this an aceepted street?yes_ no Map Numbcr Parccl Number . f.3 'Luning Information: I.J Nruperty Uimensions: Zoning Districl Proposed Uso Lot Area(sq Il) Pront�ge(il) I.5 6uilding Setbp�cks(f[) �ront YxrJ Side Y:vds Rcar Yard � Reyuimd Providcd ReyuireJ Nrovided Reyuircd ProvideJ I.6 �Vater Supply:(�I.G.L c•10,§Sd) IJ Fluud Zm�c Information: 1.8 Sewage Disposal System: Publit❑ Priva�c p "J.onc: _ Outsidc Flood"l.onc'1 Check if ycs❑ ��unicipnl O On site disposal systcm ❑ SECT►ON 2: PROPF.RTY OWNERSf11P� 2.1 Owner'ot'Record: [ Pib.ia JUl�Ui -✓irn c.nzt 5t�ce_i» rnG, C) 19 -1� Nnnw(Print) City.Stulc.ZIP . ��-oru� 120� Q98 7y0-977.3 � vv�i r3�v� a.oG c or� No. and Strcel ' 'fclaphonc C-.mnil Address SECTION 3: DF.SCRIP'f10N OF PROPOSED WORK�(check nll that apply) New Construc[iun ❑ Esisting Ruilding❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory6lJg. ❑ NumberofUnits O[her ❑ Specily: 6rief Descriptiun of Proposed Work2: �� 1 n s�—L(. / �/(f o%i�in c-tt f _,[�L. �x,/�"�uf,�,e c.r�tl�n�r��ann�— _._ .1�-- secr�o�v a: r:sr��,�•rFn coNsraucrroY cosTs �� Estimated Costs: OFficial Use Onl Labor:md blaCerials) y L l3uilding $ L E3uilding Permit Fce: $ Indicate how fee is detcrmined: �. F.,lectrical � ❑Standard City/"fown Application Fee ❑Total Project Cost'(Item 6)x multiplier s 3. Plumbing '6 �. Other Fees: $ 4. �techanical QIVAC) $ List: �. hlechanical (Pirc Su� ression) � 'fotal All Fzes: $_ Check No. Check Anwwit Cnsh Amnunt: (i. 'lbtal Nrojcct Cost $ ,j 0� , v U ❑ Paid in Pull ❑Outstanding f3alance Duc: --- S Evv o ro No u s�. �cA'L�. w( v Erz.r�� - s�v-s ,� z l�s . SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License (CSL) License Number Expir uon Date list CSI -Type (see below) Name of CSL Holder Type Description No. and Street U Unrestricted (Buildings tip to 35,000 cu, ft. R Restricted l&2 Family Dwelling Cityffown, State, ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 1 Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) FITC Registration Number Expiration Date HIC Company Name or I-IIC Registrant Name No. and Street Email address Ci[ /Town, State, ZIP Telephone SECTION 6: 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 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 1, 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. 7-17 Print Owner'sName (Electronic Signuture) 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. Gl�rn 7—/7--f4/ Print Owner's or Authorized Agent's Name r.lectronic Signuture) 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 (IIIc) Program), will not have access to the arbitration program or guaranty fund under M.G.L. o, 142A. Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.ntass.sov/dns 2. When substantial work is -planned, provide the information below: Total floor area (sq. R.) (including garage, finished basement/attics, decks or porch) Gross living area (sq. H.) _ 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 orcooling system__ Enclosed ____Open 3. "'rota) Project Square Poolage" may be substituted for `"road Project Cost" �l �IanY� f<! - O • stDIRy sa lelA rnu it 3 ., u,it'—A t+ $ - E .• 4 ,o � w�T Niw ��► w •rte _ b3 75 _ ��- Latc k I HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: -R-/`/ Job Location /S c/ pc� yet (, , , O 61 ?b Home Owner Address S'cu� MA Q lC(_-I�D Present Mailing Address S f-nr2W Aly 0 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 C�- �Gmt APPROVAL OF BUILDING INSPECTOR CITY OF SALEM, MASSACHUSETTS BUILDING DEPARuvLENT �}a5Y?sIr`I' 120 WASHINGTON STREET, 3 1D FLOOR TEL. 978 745-9595 FAX (978) 740-9846 KINIBERLEY DRISCOLL MAYOR THONIAS ST.PIERRE DIRE CTOR OF PUBLIC PROPERTY/BUILDING COMvIISSIONER HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: -R-/`/ Job Location /S c/ pc� yet (, , , O 61 ?b Home Owner Address S'cu� MA Q lC(_-I�D Present Mailing Address S f-nr2W Aly 0 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 C�- �Gmt APPROVAL OF BUILDING INSPECTOR