2A SUNSET RD - BUILDING INSPECTION (2) s ,
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, Vh edition OF SALEM
Revised✓unuary
11 I Building Permit Application To Construct, Repair, Renovate Or Demolish a l. :ooN
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Num r: Date Applied: G Q
Signature: /(J
Building Cummissio edl t uildinip Date
SECTION I:SITE INFORMATION
1. Prope�ty Address: 1.2 Assessors Map& Parcel Numbers
1.1 a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: -
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(R)
From Yard Side Yards Rear Yard
Required Provided Require) Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system O
Public❑ Private❑ Check if es❑
SECTION PROPERTY OWNERSHIP'
1 Own rt of Record: (-A
` !� (�
Name(Print) - Address for Service:
c�/li t2Y�. ( �t J l9-7F�)-91.2 —I0l1
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of P 0 osed Work':
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use only
Labor and Materials
I. Building S 1. Building Permit Fee:S Indicate how tee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S '1—
q. Mechanical (BVAC) S List: ( co r
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No._Check Amount: Cash Amount:_
Z/' 6.Total Project Cost: S SQ C) 0 Paid in Full 0 Outstanding Balance Due:
' e
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name ol'CSL•Ilulder List CSL Type(see below)
.—f-pel Dexri lion
Address U UnreslricteJ u to 35,000 Cu.Ft.
R Restricted I&2 Family Dwelling
Signature M Mason Onl
RC Residential Roafinit Covering
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 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.c. 152.f 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..........O No...........O
ECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 t C \ S as Owner of the subject property hereby
authorize `3/ l to act on my behalf,in all matters
relative to work authorized by this wilding permit application.
Signature of Owner Date
SECTION 71b:OWNER'OR AUTHORIZED AGENT DECLARATION
I ,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.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of 'u
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 Mof have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 11016 and I 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(Sq.Ft.) 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 of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
1
�A CITY OF SALEM
• PUBLIC PROPRERTY
�• DEPARTMENT
\I .1 I. I�C�.�+111\b.Q+I)rM kr r 5.11 I\I, \t.\K.\I I II V I,•.1'� .
I'FI:'/71.7�4'liys 1:%1:978.7413-946
Construction Debris Disposal Al idavit
(rcyuired I'ur all demolition wid renovation work) `
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit q is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I11. S 150A.
The debris will be transported by:
In/1 In �\ JG.WCJ�Sk-'
I ama of hauler)
The debris will be disposed of in
—
(name o17u n'Y)�—
(addnaa of facility)
Signature of lxr t applicant
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CITY OF S.U.E2M
PUBLIC PROPERTY
DEPARTMENT
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TEL Vj-73S-9S"*FAX 9747469"
HOMEOWNER LICENSE EXEIMMON
Plow Print
Date
Job Location af)
Horne Owner Address D.A S N S¢ 2
Home Owner Telephone 9 CIS— 9 12 — I o,,N
Present Mailing Address
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
hire who.does not possess a license,provided that the owner acts err supervisor.
DEFINMON OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside, on
which them is, or is intended to be, a one or two family dwellin&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 wort 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
CeePROVAL OF BUILDING INSPECTOR
other side for state code