TINKERS ISLAND - BUILDING INSPECTION (3) A
The Commonwealth of MaSSuChlISC115
Board of Building Regulations and Standards CITY OF
a Massachusetts State Building Code, 780 CMR SALEM
1 Reri.red.11ar 2011
Building Permit Application To Construct, Repair, ate Or Demolish a
One- or I wo4aruih' D ling
This Section Fo fficial Use O
Building Permit Number: Date Applicd:
Building Official(Print Narne) Si u putt
SECTION 1: SIT ORMATION
1.1�roierty Address: 1.2 Asseessssor�Y18
1* Parcel Numbers \
I.1 a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Amung District Proposed Use Lot Area(sq 11) Fronlage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: — Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if cs0
SECTION 2: PROPERTY OWNERSHIP'
2 wnert of Record:
N;mte(PTmq \ City.Slate,LIP
sA
No.and Street a Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(che k all that apply)
New Construction❑ Existing Building- Owner-Occupied>3. Repairs(s) G11 Alterations) ❑ Addition ❑
Demolition 18' .Accessory Bldg.❑ Number of Units_ Other_❑ Specify:
AI
Brief Description of Proposed Work': S \ \
Y.
\ Lo 'V\ .—
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials) Official Use Only
1. Building s 2 sz-0 . I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical g ,__ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier ___x
3. Plumbing S 2. Other Fees: S
4. .Mechanical 111\':\C'1 S List•._-_
�. ,\leehanical (Fire
15, LC551Un) S rotal All Fees: S _----------------
iG. Total Project Cost: S Check No. Check Amount ----- Cash Amount:.___. ._
(��vV ❑ Paid in Full ❑ Outstanding Balance Due:
�T Cio )
t
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(C'SL)
License Nunthcr --- Itcpirmion Dute
N:una ul'C'SI. I IulJer
List C:SL f)pe(see haloes)
No. :uoJ Street - — — -_ -- -- Type Description
U Unrestricted(Buildings up to 35,000 cu. 11.)
_ R Restricted 1 r2 Family M%ellin
Citylfoen,.Stave.ZIP M Masonry
RC Roolin g C'o\'crin
W'S Window and Siding
SF Solid Fuel Burning Appliances
I Insulation -
I11c hone F.maiI address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Registration Number Expiration Date
I IIC Company N:umc or I IIC Registrant Name
No. and Street Email address
City/Town. State,ZIP "rele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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
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 Owner's Nume(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
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(f lccvonie.Signature) 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(HIC) Program),will rro have access to the arbitration
program or guaranty fund under I.G.L.c. 1 2A. Other important information on the HIC Program can be found at
totes.imt-r,,;os ;n•i Information on the Construction Supervisor License can be found at t�_ly,S % ,II„
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.) (including garage, finished bascment'attics,decks or porch)
Gross living area(sq. 11.) Flabi(able room count
Number of tireplaces `'umber of bedrooms
Number of bathrooms _ _ _ Number of hall'baths
I')he of cooling S%stein .. _-- _- -- ncloser of decks, porches . .
I't to of heatin� system
. f _ Enclosed _..__. Open
3. 'Total Project Square Footage"nny be substituted lor'Total Project Cost"
CITY OF SALEM, &Ws,wHCSETTS
OLLWLNG DEPARTNtENT
120 W.kSHLNGTON STREET, Yo FLOOR
TEL (978) 743-959S
Fxx(978) 74069846
KIJCBERLEY DRLSCOLL
,MAYOR THows ST.Pmas&
DIRECTOR OF PL13UC PROPEATY/stmnLNG CONNISSIONER
Construction Debris Disposal Afriidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL a 40, S 54;
Building Permit Al is issued with the condition that the debris re
sulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111 S 150 A.
The debris wil
l be trans rtcd po by:
(name of hauler)
The debris will be disposed of in : C
(name of facility)
(address of facility)
C
signature o permit applicant
t "D WA
to
CITY OF SALE.Avi
PUBLIC PROPERTY
DEPARn, LENT
KlfulalaY^ter yy
.Wvaa I b VAgmac aft yru m• Suiy%(AMAc w san7 011.
HOMEOWNER LICLNSE EXE.14MON
Pleaes Frlat
Dan 0,q4� aa
Job Losoatioa u ca
Home Owner Addle» G�o
Home Owo r Telephone cl l — O
Present Mailing Address p�
The current exemption o["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 licassm provided that the owner acts as sluparvisar.
DEFINITION OF HOWOWNMt
Person(o) who owns a parcel of land on which he/she resides or intends to resides, on
which then 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 this Building O®cial,on a form acceptable to the Building
OlH64 that he/she be responsible for all such work performed under the Building
Permit.
The undersigned"homeowners"assumes responsibility for compliance with the Stan
Building Code and other applicable by-laws and regulations
The undersigned "homeownd'certitics that he/she understands the City of Salem
Building Department minimum inspection procedures andeqUUiRuftfsand that he/she
.Will comply with said proc req '
HOMEOWNERS SIGNATL
APPROVAL OF BUILDING ECT
Sce other side for state code