Loading...
16 VICTORY RD - BUILDING INSPECTION (3) The Commonwealth of Massachusetts r'/ 4 Board of Building Regulations and Standards CITY OF m rMassachusetts State Building Code, 780 CNIR Sd Var,G 'i71 Revised Mar20/l I)I Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling 'Chis Section,For`OfHcial Use my ` Building Permit Number:- Date Appl d°; r Building Official(Print Name) _Signature Date SECTION 1: SITE INFORMATION 1.1 P.ropert 1.2 Assessors Map& Parcel Numbers /C I/7Addc> y K iD _ 1.1a Is this an accepted street? yes_ no bfap Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks (ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.O.L 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 yes❑ SECTION 1;'PROPERTY OWNERSH '°. 2.1r,Owrof n — o Name(Print) /`-� City,State,ZIP No. and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK,(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': 1 SECTION 4: ESTIMATED CONSTRUCTION COSTS- Estimated Costs: Item Official Use Only... Labor and Nlaterials I. Building $ 1. Building PermitFee S Indicate how fee is determined: ❑ Standard City/Gown Application Fee 2. Electrical S ❑ s - "Coral Project Cost (Item.6)x multiplier x 3. Plumbing S 2. Other Fees: .$ 1, %lechanical (IIVAC) S List: 5. Mechanical (Piro $ . Sop ression) _ l'otal All Fees: .$_ Check No. Check Amount: Cash Amount. Cutal Project Cost 3 ��z�O. 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CoNSTRucrION SERVICES 5.1 Construction Supervisor License(CSL) License Number E.piration Date Name of CSL I folder List CSL Type(see below) No. and Street WRRestricted Description - icted BUddin s u to li.000 cu. R. ted 1&2 Famil n, e, lmnCityrrown, State, `LIP Coverinw and Sidinuel (turning Appliances I Insulation Tclz hone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name No.and Street Email address City/Town, State, ZIP Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L.c. 152. 1 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 Name(Electronic Signature) Date SECTION 7h: 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. 3 zt �3 Print Owner's or Audwriud:\gent's N;une(Electronic Signature) D;rt NOTES: I. :\n 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 not have access to the arbitration program or guaranty tint!under NLG.L. c. 142A. Other important information on the MC Program can be found at ww�wxmss.,�uvioca Information on the Construction Supervisor License can be found at ww•w.ntass.eo�:41L 2. When substantial work is planned,provide the information below: Total floor area(Sq. ff.)- _ (including garage, finished basement/attics, decks or porch) t7rosi living area(Sq. ft.) _ Habitable room count Number oftireplacas_. _-- _ Number of bedrooms --- ------_-- Number of bathrooms Numberof haltibaths _- l'ypc or heatingsysteut Number of,leeks/Porches ..... .... --- fgpcorcoolingsyilan--------_---_--_ F.uclo;nl_ _ --- _ -_--()pen 1. "Folal Project Squire Foot:,,,e" may be iubstihitcd t,)J' I'rojzct (bst" CITY OF 5.U.E.Nf PUBLIC PROPERTY DEPARTOMENT u a..►ir ouanu to.ras,s.ss" •r.u. HOMEOWNER LICENSB EXICIM ON P1aw trtet Dam /3 !ob Location 6 V l(,TOR Y fe G� SSG BLit , Jai e� Homo Owmes Addrees ' Home Owner?elephow Preamt Mailing Address The current exemption off"Homeowners"was extended to include owner-occupied dwellings of two Units or feu and to allow.suds homeowners to engage an individual for him who does not possese a license provided that the owner acts as supervisor. DEFINMON OF HOMOWNMt Peraoo(s) wise owns a pared otlamd on which Adobe resides or intersds to reside.on which there iti or is intended to be,a and or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than erne home in a two year period sh"not be considered a homeowerr. 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 "homeownd'assumes responsibility for compliance with the State Building Code and other applicable bylaws and regulations. The undernigned "homeowner"certifies that helsho undentands 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 9UfLDLYG SPE OR See other side for state coda Y CITY OF S:UIIEtiI) A-uSACH USE ITS ©L'(LDL\G 1)EP.ART\tEIiT 1 '0 %V-NSHLYGTON STRE w ET, 1 FLOOR —� T EL (978) 745-9595 KI.NfB RLEY DRISCOLL F.VX(978) 740-9346 A L�YO t TT-Iosw ST.PIERRs MxECTOR OF PUBLIC PROPERTY/8C1LDL%tG C0J0(!55[UNER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 CNTR section It 1.5 Debris, and the provisions of tiMGL c 40, S 54; Building Permit ht is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by 141GL c I 11, S 150A. The debris will be transported by: �C��uc�pgsfr3s��. (numc of hauler) The debris will be disposed of in (name of racaity) (address of tacilitY) signature ufpe mtt applicant Z� J c --- id+, ..iii b;e 1 I�