16 VICTORY RD - BUILDING INSPECTION (4) rF i a
the Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
�g f Massachusetts Slate Building Code, 780 CNIR SALE\I
/1 / tL,•• lt.•rietJ.IGu _'lll/
(� Building Permit Application To Construct, Repair. Renovate Or Demolish a
One-or Two-Fo nilt Divellin,tr
This Section For 01filcial Use Only
Building Permit Number: ate Applied:
Building 0111cial(Print Nwne) Sign Date
SECTION I:SITE INFORMATION
t. Properly Addres • 1.2 Assessors Map& Parcel Numbers ---•�
� U/LT�(Zy fZ. f�
I.la Is this an accepted street?yes no Map Number Purcel Number
1.3 Zoning Information: 1.4 Property Dimenslons:
Zoning District Proposed Use Lot Area IN It) Frontage III)
1.5 Bullding Setbacks(R)
Front Yard Side Yards Rear Yard
Required I'ruvided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40,554) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal O On site dispuwl s .tun
Check if ros❑ >� ❑
SECTION2: PROPERTYOWNERSHIPI
2.1 Ownert of Record:
Name(Print) city,
G 8�2
i� Ols cJ/p �1,11P 4f o ��c� /, it
Nu.and Street 16 l L"TO Tee hone '� 5 C/
V Email Address
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
NewConstruction ❑ E.xistingBuilding❑ Owner-Occupied ❑ Repairs(s) Cl Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.Cl Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
M
ECTION a: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:ILabur and .\lalerials) Official Use Only
ing S I. Building Permit Fee: f Indicate how fee is determined:
ical S ❑Standard CityrTosvn Application Fee
O Total Project Cost'(Item 6).x multiplier x
ing S L Other Fees: Snie,tl II11'.\('1 S Lisl:nic;d (Fireiom S Total \Il Fces: SCheck .Nu. ('hcck :\nmltt: C,uh \Iwnun: _
Project Cost: 'S g(Jb ❑paid in Full Cl Outstanding 13.1ktnce Due:
SECTION 5: CONS7'RUC'riON SFRVI( F:S
5.1 Construction Supervisor License(CSL)
I imnse Numhcr --' --- f\piradoo Rite
Name of l'.SI. I IulJcr
I ist l'SI. i)pe Isee bclutt l
---- ---------- ------------ 1')pe Description
No. .ind Slrcel
U I Inrestricled I1luildin+s on to 3).0(10 ut. It
_ .._.__—_—.. . . Ii Restricted 1 r2 Family Dwcitin
Cit)i fo+t n,Slate.LlP M Masonry
RC Rooting Covering
...—. W'S Window and Siding
SF Solid Fuel]]timing Appliances
I Insulation
Iele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
IIIC Registration Number F.spinuiun Date
IIIC Compan) Name or IIIC Registrant Name
No.and Street Email address
City/Town.State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.1 I5C(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...........C!
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 U%mcr's Name(Electronic Signature) Date
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 is application is true and accurate to the best of my knowledge and understanding.
14 /
r' Ossncrsor:\u ulriieJ,\gcn ;unelFlectrnnicSign:mlro) DUN
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 no 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
a t++1 m.n. Information on the Construction Supervisor License can be round at 1+)tn nl,la:Sio% .III,
2, %%'lien substantial work is planned, provide the information below:
Total floor area 1 sq. ft.) _ (including garage, finished basement attics.decks or porch I
Groh living area 1 sq. it.l ._._ . Habitable room count
Number of fireplaces _ _ Number of hedrooms
Number of hndtrooms . . Number of half bmI1S
i
I'.pc of heating s)slnm Number of decks, porches
I\pe ofcoollllg s%ston _ 1*I1closed _ -_I 11+e11
1. "]'+dal Project Square Footage"m;% he substituted for"focal Project Cost"
CITY OF S.U.EM
PUBLIC PROPERTY
DEPAjamENT
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wrae i]a essrncron stunt•suaK w.o�oa ssrn ON'0
M 9'10+5.9s"•F%x f'i7r69W
HOMEOWNER LICENSB EXEMMON
P1eaw Met/.I
DAN /
Job Looados/� 1116-1-�Zy e P
Home Owner Address M 0
Hom.Owner relephoae 9 7 r SS94-' Sz G
?read Mailing Address
The current exemption of"Homeowners"was extended to include owner-ecupied
dweUings of two Unite or lea and to allow such homeowners to engage an individual for
hire who.doe not possess a Howse provided that the owner acts as supervisor.
DERNMON OF HOMEOWNER
Person(s) who owns a paned of land on which Wdw reside.or intends to reside.on
which there is, or is intended to bat,a on@ or two lir0*dwelling, attached or detached
structures accessory to such use and/or fum structures. A penis 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
OfllciaL 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 bylaws and regulations
The undenigned "homeowner"certiffes that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
.viIf comply with said procedures and requirements.
HOMEOWNERS SIGNATL
APPROVAL OF SUILDENG NSPECTOR
See other side for state cods