24 SUNSET RD - BUILDING INSPECTION i� - ICI - � ZI � cr: I � za z�
The Commonwealth of Massachusetts RECEIVED
F 'yg Board of Building Regulations and Stand<WSPECTIONAL SE VICLC$TY OF
'I!/ Massachusetts State Building Code, 780 CMR SALEM
Revi.W d Mar 2011
Building Permit Application To Construct, Repair, Renovala*WbAlBh A S 22 `
One-or Tivo-Family Divelling
This Section For Official Use Only
Building Permit Number: Date A 'ed:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property kddress: 1.2 Assessors Map& Parcel Numbers
xL I a Is this an accepted street?ycs V no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sy 11) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Writer Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ 'Zone: _ Outside Flood Zone'?
Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2. Owned of Record:
une('PrinlfJ' City,Stale,ZIP
� 7 ��n9ef Z c! (,l~ Q ��te�iSTCoyt3( 4�/4,I cop;,
No.and Street "Telephone I'ma Addmss
SECTION 3: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:____
Brief Description of Proposed Work'':
a'�oVe f_Gca f^�''mSrS G.c� aY, ANT /�,2CatZeA_'CEC ftal�Qe
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building $ 1 I. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees:
4. Mechanical (I IVAC) $ List: ) r
T�
5. Mechanical (Fire
Su)pression) $ Total All Fees: $
6. Total Project Cost $
Check No. __Check Amount: Cash Amount__
q
d �OC> ❑ Paid in Full ❑Outstanding Balance Due:
ST T-C) ��. � .
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
I^r
tea �f*l License Number E:vpiralmn Date
Name of CSL Holder
S� ? A List CSL'fype(see below)
No.and Street Type Description
U Unrestricted(Buildings tip to 35,000 cu. ft.)
Citv/town,State,ZIP R Restricted 1&2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telc hone Email address D Demolition
5.2 Registered home Improvement Contractor(HIC)
umlxr
I IIC Company Name or I-IIC Registrant Name FIIC Registration N Expiration Date
No.and Street
- Email address
City/Town,State,ZIP Tel- hone
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 CONIPLETED 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.
Print Owner's Name(Electronic Signature) 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
AcontdAqplicationis t accurate to the best of my knowledge and understanding.
114-
gau's ame(Plectronic Sig ature) Da c
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 riot have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.sov/oca Information on the Construction Supervisor License can be found at www.ntass.eov/dos
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. ft.) Habitable room count
Number of fireplaces _ Number of bedrooms _
Number of bathrooms _ Numberofhalf/baths _
"Type of heating system Number of decks/porches _
Type ofcooling system Enclosed_____Open
3. `Total Project Square Footage" may be substituted for"Total Project Cost"
` �. CITY OF SALEM, MASSACHUSETTS
BUILDING DEPAR NIENT
120 WriSI-IINGTON STREET,3RD FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KINIBERLEY DRISCOLL
MAYOR THomm STYIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONLVUSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date pp \
Job Location of`�A1-— &mq,-f 24, J4ie,, /"!//,�k l o �
Home Owner Address F�M
Present Mailing Address S A M 9
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'SSIGNATURE- I /¢
APPROVAL OF BUILDING INSPECT R
k
tip,...
CITY O F S:1L: M, N L-1S&: CFI US ETTS
/ J 4 120 1 ASI-ILYGTON STRE$T, J °FLOOR
T EL (979) 7 s5-9595
KINIDE111 EY MUSCOLL FAA(973) 7'W-93M
NLAY0,2 I IOSCI3 ST.PI^eRRQ
DtRECTOROF PUBLIC PROPEATy/BL:M.OLNGCO\L,1,SS[O. ER
Construction Debris Disposal r1t'Hdavit
(required tar all demolition +u1d renovation work)
In accardance with the sixth edition of the State Building Code, 730 Ci+,IR t I
Debris, mid the provisions of IMOL c 40, S Sd; section l .5
Building Permit 4is issued with the condition that the debris resulting
this work shall be disposed of in a properly licensed waster dispasal racility as defined by I�rGfr
Lom
l l 1, S 150A.
Tile debris will be transported by:
At:
("ware ut'hauly
The ticbris will bo disposed Orin
1�Iwtll(p p(tlCfflil(.It)PIIC.�� / /�
i
q
:y
li t r
;
r
s:
a
n ,
r -
aS
s
: k g J.' .6 • ..i i
t i E 4s.� 4r
a•'
1 {
4
fi
9�
Print-Maps. Page 1 of 1
I;p bing Maps
Salem, MA
24 Sunset Road
Salem, MA 01970
1k
® Or,the rya"+Use m.tring.com to find maps,
® de'eetions.bus.nasses.and more.
4
IC
Bird's eye view maps can't be printed, so another map view has been substituted.
http://www.bing.com/maps/print.aspx?mkt=en-us&z=l 9.9252096690785 87&s=o&cp=42.4... 4/2/2014