16 VICTORY RD - BUILDING INSPECTION (5) 1'lle C'onunonwealth of.Massachuseus
i hoard of Building Regulations and Standards Cl I1'OF
sr i Massachttselts Slate Building Code, 7SO CNIR SALE,M
'ti'-•• Htri.erJ Ilur ' l
11jilding Permit Application 'ro Construct. Repair, Renovate Or De tolish
(Are-or Tuv-FinniA Du ellhnq
This Section For Official Use Only
Building Permit Number. _ Date Ap ied:
Building 011icial(Print Mane) Signalu Date
SECTION I: SITE INFORMATION
1.1 Pro perty/Addrrss,: 1.2 Assessors Map& Parcel Numbers
I.la Is this an acce ted ree . ej— no — Map NuniNr Parcel NuniNr
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District I'mposcd tJsc Lot Arco(sq 11) Pronlage(11)
1.3 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1.c.40,§Jq) 1.7 Flood Zone Information: 1.8 Sewage Dbposal System:
Public;? Private O Zone: _ Outside Flood-Lone?
Check if cs6� Municipal IJispowl s)slem ❑
SECTION2: PROPERTY OWNERSHIP
2.1 q>rger, Record
e
Naule(((1-rfit) I_ /��p�� City,Si tc ZIP
�6 f�/GT(J✓[1 r d, R7 - C) rhea
Nu.and Stroe Telephone :mail Address e
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building❑ Owner•Occupied ❑ Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work=:
SECTION J: ESTIMATED CONSTRUCTION COSTS
11cm Estimated Casts:
ILabor and Materialsi OMclal Use Only
1. Building S �'�d -� I. Building Permit Fee: f Indicate how fee is determined:
'. 1:1wrical S ❑Standard City,Town Application Fee
❑Total Project Cost'(Item 6)x j multiplier _..— x 1. Phunhi°g S 1. Other Fees: S p — - --- -
a. \lcchanic,d III\'.1(') $ List:
9 \Icchunical (Fire
tiu,ucssionl $ � Total All Fees:
- - —
in Check Nu. _('heck Amount C.ish \meant:o llslul Project CnsC S / 5 %r ❑Pail in Full 13 Outstanding Bal;tnce Due:
SEC"PION 5: C'ONSI'Rl1C'riON SERVIC'F.S
5.1 Construction Supenisur Liccose ICSLI _
I iwnsc Nhlmher _ Pvl+ir lwo Date
N:une of l'SI. Ilulder ... I ist CSI. I Pc(Wc halo+\)--_" -_
___ _ _---- ---- - -------- pc Description
No ml i Street ---- _— _-- LI Ulvestricicd I IIuilJin s+i u+ 15,1111(1 eu. IL1
R Re.tricled U2I'.111111 Ihwlli11
Cilyi town..Slate,LIP -- ---_. . \I \la:un
RC Rool'ing Covering
µ'S µ'indoor mid SWIM
-- SF Solid Puel Burning Appliances
I Insulutun
'talc hone hmail address D Dcnu+l!lion
5,2 Registered Home Improvement Contractor(HIC)
I IIC Itegistnnion Nonit cr F.cpirnliun Datc
I IIC'Company N;une nr I IIC Itegisrmn Nanw
No.mid Street Email address
City/Town,State,ZIP Tcle hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e. 152.1 25C(6))
Workers Compensalion 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
SECTION 7s:OWNER AUTHORIZATION TO BE C0111PLETED 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 Uwncr's Nat(Elccltunic Signature) Date
SECTION 7b:OWNER' OR AUTIIORIZED 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.
a T
An✓!e l�len l o echo
Print Owned/or,Nuthonnd Agent s Noma 11.1¢Urunnv Slgnahuvl
NOTES:
I. :Nn Owner who obtains a building permit to do his her own work,or an owner who hires an unregistered contractor
(not registered in the Hume Improvement Cuntractor i HIC)Program).will nu have access to the arbitration
program or guarmty fund under M.G.L.c. 1 a_2A.Other important information on the HIC Program can be found at
www m.r•, + ,,, I Information on the Construction Supervisor License can be found at
2. o'hen substmuia[work is planned,provide the information below:
rota) floor area lsy. R.) _ ____--_B including garage. tinishcd basement attics,decks or porch)
Gross Ii\ing area(s+ 11.1 .--_- Habitable room count
Gunbcrol'tircplaces - \'umherotl+cdruoms
\ulhcr of hadvom ns — - �'umbcr oflialf hull's
n
I\lie ofheatingsystem . . _ Vumhcral'dceks, pordlcs
Inclosed -'Open
I l 1 pe UI P§+ lltg iUle 111
I
t. "loial Proje❑ Squxe l'oolJgc"nl;H be sobstilt"d for"Total Project Cost'
CITY OF SALE.Nt
PUBLIC PROPERTY
DEPARTMENT
u,s�oeernu
.Nuwn 130WASmaGnMRfesr•114 WmAnasmsolM
TILL Y'.a•Ni9Sf!•FAX 978-1469646
HOMEOWNER LICLNSE EXE.MMON
Plow "I
Date a a 3
Job Location lv IJ t 9 I/Home Owner Address _
Home Owner?elepbone O /
Present Itdailing Address <�7 Gc-14�—
The current exemption of"Fiomeowners"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 licenser provided that the owner acts as supervisor.
DEFINITION OF HOWOWNEA
Person(s)who owns a parcel of land on which he/she resides or intends to reside, on
which there 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
'Imeowner'shall submit to the Building O®ciaL on a fora acceptable to the Building
Otlticial.,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 reguladons.
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 SIGNATLIM
.APPROVAL OF BUILDING ClSPECTOR
See other side for state code
CITY OF SAL&Nf, .bL1SS.ICHL'SETTS
at;MDLNG DEP.1M NT
120 W.U1404GTON STRSBT, JW FZOOR
TEL (978) 745-9395
KI1CSFRlFY 0RMOLL FAX(973) 740.984
.tifAYOlt D'OMU ST-PMXAS
D"'CrOt OF PCBLIC PROvet7Y/9(;MDNG CO-%nnSSrO,N eR
Construction Debrij Disposal At'tldavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 1 11.J
Debris, and the provisions of MCL c 40, S 34;
Building Permit M is issued with the condition that the debris resulting tom
this work shall be disposed of in a properly licerned waste disposal facility as daRncd by&,GL c
11 I, S I JOA.
The de 's will be transported by:
(name ot'hoular)
The debris will be disposed of in :
(name o�ally) '.
(iddrerr of rail �Y1
uynanrre o(permit pp6unt
�12- i oL
,!4(6 -