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28 UPHAM ST - BUILDING INSPECTION (2) n r � _ :� I'ha C'anulwnwc:3hh uf,blasiaihu>cits —_ Ilo,ird of Building Regulations mod Scmdards CI OF 3 Massachusetts Sl;ltc Building Cute. 780 CNIR SALEM 1 I Rri.iJ Ildr.17// Building Pcrnnil Application 'ro Construct. Repair. Renovate Or Demolish a l (hle-ur riru-f'unnh Di,eRin,\r This Section For Olticial Use 0 Building Permit Number: _ Date Applie . IIuilJing Ullicial(I'rinl N,une) Siaptalurc DJ1e SECTION 1:SITE INFORMATION I., Pro�3erty Address: 1.2 Assessurs slap dt Parcel Numbers 1.la Is this unaccepted street? es no Map Number 1'urccl Numher I.! Zoning Information: 1.4 Property Dimensionst Laning District Proposed U10 Lo(Amu IN 11) Fronlaga(Ill 1.5 Building Setbacks(R) Front Yard Side Yams Rear Yard Required Provided Required Provided - Required Provided 1.6 Water Supply:(M.G.I.C. 40,§St) 1.7 Flood Zone Informatlom 1.8 Sewage Disposal System: Ribtic❑ Prls ate❑ Zone: _ Outside Flood Zone? Check if ycsO Municipal❑ On site disposal 1)swm ❑ SECTION2: PROPERTY OWNERSHIP' 2.1 Owners of Re oral• F_dW CAnr n Sa I 'e Name(Print) City.Same,ZIP dL� k3 5+ • q7?- 7V-qtfy5 Q � r✓��f(� Concalfi.nf No.and Street relephune Email Addrcls SECTION l: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ E.vistiny Building❑ Owner-Occupied ❑ Repairst3) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specily: Brief Description of P opost Work",_ a ut V t_ `A S f u r e G S o GA r �C e, p e n G r SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: (Labor mtd Materials) Official Ust Only 1. Building S I. Building Permit Fee: S Indicate how lee is determined: '. Llcarical S ❑Standard CityTo%%n Application Fee ❑Total Project Cost'(Item 6)x multiplier i t I'lumhi°g S ?, Other Fees: S - -- - J. \Ica,.ulii.tl ,II\ 1('1 S List._ x . i 1�u presiona S rood .\itFees: S ( hrcA Vo. ChecA :\mount l'a,h \uenun: I �r!rulal Isnrjecl Cml ) Oa O .60 O P.,id in Full 0 Oolstanding BaLuice Due: SF:(-I IONS: ONS I Ri1c rJON SF14% K FS S.l ('onstructiun Super%i.%or Licenbe K Si-) meol L SI I lo I dvr I M L S 1. 1'%IV I•vv I�PC I)ot;ription No. tlid',Irvvt ti itlirv.strivij 111illidjo sit sli to 35.0011 oll ILI It litc,tricted IS] I..111111 Dwvlhll M Mason IW R,%,Iin L',,%erin A S Willjow acid Sidill SF Sulid Fuel Burning lipplialices I Insulation D Demolition Pale ii address .1.2 4 —Registered I Joint I nil)rus emen I Content:gar III IC) — I IIC 11vitibiration Milliner F\11iriltioll Date I 11C 01111pall) Name or licilistrant Name Email address No. and Street Citv/Town I'Vic hone SECTION Gi WORKERS,COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 153. 1 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this afflilavit will result in the denial of the issuance or the building permit. Signed A MdAvit Attached? yes .......... E3 No...... CI SECTION 78:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1. as Owner or the subject property,hereby authorize to act on my behalf,In all matters relative to work authorized by this building permit application. Date Print Uwner's Nutne(Eicutrunic Signature) SECTION 7b:OWNER' 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 ap ication is true and accurate to the best army knowledge and understanding. We� -z- i Mig I'rinl Owner's or signutirg) NOTES: � I —F,—.\n O\%ner�% - his-litir o%vn %wrk.oran owner who hires an unregistered contractor sho Mains a building poinit 10 aO will LUi have access to the arbitration I not registered in the Home Improvement Contractor(HIC) Programt. program or guarint) fund under M.G.L. v. 142A. Other important inrurniation on the HIC Program van be l'ound at I information on the Construction Supervisor License can be found at,,k%„ w 1,- 11—en substantial\%ork is planned, preside the 111ur1n1ictliuodni bgc lgo�va ge. Imished basement atics, decks or rord i roiji floor area I iq. 11 Habimble roam count Gross li%ingarea 154. \t1111her ot'hedromus Number ot hall hall" \umber,il hathrooms \j,jjjhvrot'dcvki porches I%Ile'll Iv.11ilIg ')'teln j'c ofcoolille 1*11vio'cd I he •jlb,jjltltc,i 6%tr loi.il Project Cobh- r CITY OF SA EM PUBLIC PROPERTY DEPARTMENT u a•,aa+r o•an�u wvoe i]a slww.�a.snusr•su„�Vwo�ow seen Ot.'e tta.rasr>ssft •r..a.r.�swsw HOMEOWNER LICLNSB EXEM"JOIN Plesae Mat Date 1 1 Z I z- Job Location Home Owner Address IR v � 5 Home Owner Telephtme q 1 4 - Preaed Msigng Address a he current exemption oll"Homeowners"was extended to include owner-occupied dwellings of two Unity of teas and to allows Such homeowners to engage an individual rot hire *be does not possess a licensed provided that the owner acts as supervisor. DEFINITION OP HOMEOWNER Parson(a) wbs owns a patesl of land on Which WSW resides or intends to reside,on which there is, or is intended to bq a one or two family dweWns 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 Otlleia& on a form acceptable to the Building Official, that ho(she be responsible for all such work performed under the Building Permit The underrigned "homeowner"ustunce responsibility for compliance with the State Building Code and other applicable by6laws and regulations The undersigned "homeowner''certifies that helshe understands the City of Salem Building Department minimum inspection procedures and requirements and that helshe Will comply with said procedures and requirements. r HOMEOWNERS SIGNATLAB .APPROVAL OF BUILDING NSPECTOR Sce other side for state code CITY OF S.IL&Nr, AUSACHUSETTS t3C wow OEP.1ATtLNr I'0 WASHO GTON STIW, 1'4 FtOOA Ttl. k978) 745-9395 KOWERF AY OALSCOLL P.IX(97� 1 984d MAYOR T} oswStPmux 1)rmcro•a Pt auc pROFIATY/at:MDCrC GO\L%ltsstO,V EA Construction Debris Disposal Affidavit (required for sU demolition and renovation work) rn accordance with the sixth edition of the State Building Code, 780 C,MR section I 1 I.1 Oebris, and the provisions of MOL o 40, S 34; Building Permit a 1 is issued with the condition that the debris resulting from 1 11, S 1 JOA.1 work shall be disposed of in a properly licemed waste disposal racility as defined by,bICL c The debris will be transported by: YLk t©4c ( Goo (name orhauler) The debris will be disposed of in : (name or raaility) (iddrVif of r,,,l,iy) r u�namra orpermit ipphunl