2 A SUNSET RD - BUILDING INSPECTION /1 The Commonwealth of Massachusetts Town of�
a
Board of Building Regulations and Standards
r Massachusetts State Building Code. 780 CMR, Ts edition Building Dept
Budding Permit Application To Construct. Repair. Renovate Or Demolish
One. or Tou-Fonuls•DnwOmg
This Section For Official Use Onl
Building Permit Number /J Date Applied:
Signature: `sp � O
Building Commnstoner/inspector of Buildings Date
SECTION 1: SITE INFORMATION
I.1 Py„rope Address: � n 1.2 Assessors Map! Parcel Numbers
�'rl TU'tvS2k \�
t.la Is this an arc teal strew'!yes -� M no W Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning Dninct Proposed Use Lot Area(sq Iq Frontage(it)
1.3 Building Setbacks(n)
Front and Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c. 46.154) 1.7 Flood Zone Information: 1.5 Sesraga Disposal System:
Zone: _ Outside Flood Zar7 Municipal O On site disposal system O
Public'd Privan O Checkil'yeac '.
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owoe 'of Record* oZ 1\ 5 2� ILC
I`Y\ 1 C�O.e-\ �II§WtTrS��
Name(Pnm Address for Service:
9???—if2--loll
Sitptnure Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building( Owner-Occupied 0 Repairs(s) 13 1 Alieration(s) Addition O
Demolition O Accessory Bldg.O Number of Units_ Othw O Specify:
Brief Description of Proposed Work':
nc \ \opt e 1 N se C:-} I ip
IaC� rSECTION 1: ESTIMATED CONSTRUCTION CEstimated Costs: ORlelaItem Lar and Materials1. Building S - 1. Building Permit Fee: S how fee is determined:O Standard City/Town Applic1 Electrical S O Total "act Cost'(Item 6)a xPlumbing S 2. OtherFees: Sd� ^ „_f„a. Mechamcal IHVAC) S List: (_��'1s Nechantcal (Fire S Total All Fees. S
Su res.cionCheck No. _Check AmouCash Amount:_6 Total Project Cost S 0 , p Pmdm full O Outsnce Due:
1
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Super%isor(CSL)
L i%cnw Number Espuation Date
Nyee tit CSL Ilpldet Ltst CSL Type(sec below)
A,Idrrss Tw off I Description
U I Unrestricted(up to J7.000 Cu. Ft
R I Restricted 1!2 Family Dwellm
Sid"ture N 1 Naw only
RC I Residential Roofing Covering
Telephone W S Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D I Residential Demolin
15.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. ISL 12SC(6))
Worker Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this aRtlavit will result in the denial of the Issuance of the building permit.
Signal Affidavit Attached? yes..........O No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, / Vie,w a� s k t as Owner of the subject property hereby
authorize / to act on my behalf,in all matters
relative to work authori by this buildi permit application.
Signature of Owner Data
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Rine Narne
Signature of Owner or Authorized Agent Date
Si red under the pains and penalties ofperjury)
NOTES:
1. 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 Bg have access to the arbitration
program or guaranty fund under M.G.L. c. 1 42A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can lx found in 780 CMR Regulation 110 R6 and 1 IO.RS,respectively.
2. When substantial work is planned,provide the information below
Total floors area(Sq. Ft.) (including garage. finished basement/attics.decks or porch)
Gross living area ISq. F1.1 Habitable room count
:Number of fireplaces V umber of bedrooms
Number of bathrooms Number of halfbaths -
Tvpe of heating system Number of decks/porches
Tspeuf cooling system Enclo.ed Open
1 "Tool Prolect Syuare Footage'may he.uhsrituted for Total Prolect Cost"
CITY OF SALE.Nf
PUBLIC PROPERTY
DEPARTMENT
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rEL 9711.715-9S"* F.Ax 975-7469&4
HOMEOWNER LICENSE EXEMPTION
Plesse PtriM12
Date D— �
Job Location
Home Owner Address call., R ��\e n i} M f\
Homeowner Telephone
Present Mailing Address Sb xv�
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 who.does not possess a license,provided that the owner acts as supervisor.
DEFINMON 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 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 BUILDING INSPECTOR
See other side for state code