The URL can be used to link to this page

11 STORY ST - BUILDING INSPECTION (2) t _ Wl I >, The C'ununonweuhh of Massachusetts Board of Building Regulations and Standards CI I'1'OF Massachusetts State Building Cute. 780 MRti,\LL'\I 'ti,,•• H.•risrd,l6n•'Ul1 Building Permit Application To Construct, Repair, Renovate Den )li a One-or ruvr-fiunilr Dirdl(ing This Section For Of Use Onl Building Permit Number: Date Applic : J Building 011icial(Print M ne) Signa ItT SECTION I:SITE INFORMATION I.I Property Address: 1.2 Assessors blap& Parcel Numbers I.la Is this an acre led street?yes no �.. Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(ey It) Frontage ill) 1.5 Building Setbacks(it) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.I.c.40.§Sq) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone?Check if)nsO Municipal❑ On site disposal s)stcm ❑ SECTION2: PROPERTY OWNERSHIP' 2.1 Owner'or Record: / Name(Print) City.stale,Z.I P , l.co Nu.and Street Telephone Fr, ail ddnss SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ .Specify: Brief Description of Proposed Work=: EAt.aeE Am>yei:iL--\ 5ti-aJ SECTION y: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and Materials) OMNI Use Only I. Building $ I. Building Permit Fee: $ Indicate how fee is determined: 2. Elwrical $ ❑Standard City Application Fee ❑Total Project Cost'(Item 6)x multiplier _ — x 7, Plumbing $ � — - --- . Other Fees: S �- �. \kch;unc,tl III\'.1('1 S List: /Q +uessionl Tonal .\Il Fees:heck Vu. ('hak :\nitnt: C,uh \mount:lu . Total Project Cost: i 7©Q / 0 P;lid in Full 0 UutstanJing Bal:mce fhtc: e i SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) LICCIINC Nwnhcr ---- --- I \111ralinn Date Nmnc of(S1, I loldcr I i9t CSI. I)Ie Isec hcuw) h)PC Description U I orestricted(Buildings tin to 15,000 cu. It.l _ It Restricted I 2(:unit D\\cllin Cit)i fu\\n,S(aac./IP 1, Slasun RC' Rtxdin C'orcritt .-.—. W'S I Window;md Siding SF Solid fuel homing Appliances Insulation Ielc hone Finail address D Demolition 5.2 Registered home Improvement ContractorlHlC) I IIC Registration Number Fxpirttion Date I IIC C ompan) Name or I IIC Registrant Name No.and Street [:mail address City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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...........O 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 O\atcr's Nane(Electronic Signature) Date SECTION 7b:OWNERn 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. Prii U ner'. or:\udt 'icd Agent's N;une I llectronic Signanve) Dale NOTES: I. An Owner\rho obtains a building permit to do his.her own work,or an owner who hires an unregistered contractor (nut registered in the Hone Improvement Contractor(HIC) Program),will no have access to the arbitration program or guaranty fund under I.G.L. c. 142A.Other important information on the HIC Program can be found at \\\\a m t,, o,,I Information on the Construction Supervisor License can be found at\\)\t, nm,; 1111, �. When substantial\wrk is planned,provide the information below: (oral Iloor area(sq. R.1 _ 1 including garage, finished basement attics,decks or porch) Gross lking area l sq. it.) ._-_- _ ___. . Habitable room count \umber ul lircplaccs. -_- Number ol'hcdrooms Number ol'bmhruums Number of,halt haths I)pc of heating s)stem .. . _ ._ Number o(dccks, porches - I\pe,deoololgs\itelil fltcoxd _ _ --Ope❑ 1. "1otal Project Square FoolagC"nta) be suhslitutcd Rtr"fulal Prujecl C'osf. CITY OF Slv1 &Nfl INLUSACHUSETTS 8L' mc; OEP.IATTLL\T 110 W.ks"GTON ST11M, Ya FtO00. iEL (978) 745-9599 KMCBERF SY OUXoj.L F.lx(978) 740.98" N1 YOx THo.�wST.P>g1Uts DIaELTOL OP PCBLlC P1tOPEItTY/8CQALN(;CO-%O11SSIONEA Construction Debris Disposal AftIdavit (required for all demolition and rcnavation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 1 l I.5 Debris, and the provisions of MGL a 40, S 54; Building Permit # is issued with the condition that the debris resulting from I I work shell be disposed of in a properly I II, S ISOA. licensed waste disposal facility as defined by NIGL c The debris will be transported by: �Ll �' ` 7SPOSAL. (mime bf S hauler) The debris will be disposed of in l (name o- (iddrns of f�cihry) ynamre ofpermt]PPliunt Tie I,nn wf!.y CITY OF S.V-EN( PUBLIC PROPERTY DEPARTOMENT w,a. i>omara•►wrowsnaa*•s.u,a VnsuowsrrnOtfro i1t f'�7+s 9ss!•FAX 9'8.7409Ne HOMEOWNER LIMNSB EXEM"10M P1ew Mat Due lob Lacadoe 1 \ s o2; s 7- Flom Owner AddressGam-— Home Owner Telephone 1-415-9 9 x- a t o Proud Mailing Addis 74 c1 The current exemption of"Homeowneve was exterded to include owner-0ceupied dwellings of two Units or leas and to allow such homeowners to engage an individual for hire who.does not possess a lic n 4 provided that the owner acts as supervisor. DEFINMON OF HOMEOWNER Pawns) who owns a psaeAl of land on which he/she red"or Intends to reside,on which there is, or is intended to bs6 a one or two 13 a*dwelling, attached or detached structures accessory to such use and/or fan stttuctwes. 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 Otaeial,on a torn acceptable to the Building Official, that he/she be responsible for all such work performed under the Building Pernnit The undersigned"homeowner"auurnes responsibility for compliance with the State Building Code and other applicable bylaws 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 Will comply with said procedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF SUILDENG MPECTOR See other side for state code