2 WALTER ST - BUILDING INSPECTION s 1
a� The C'ummunwealth of Massachusetts
i� Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CNIR SALEM
Building Permit Application To Construct, Repair, Renovate Or Denlolish a Keri,ri•,/.1Lu•_'ill l
One-or Two-Fumllr Dwelling
This Section For 0 iul Use Onl
Building Permit Number: ate Applied:
Uuddmg 011mial(Print Nmne)
Signature [ ate
SECTION I:SITE INFORMATION
I Property Address:L 1.2 Assessors INC & reel Numbers
I.la Is this an accepted street?yes ✓ no Map Numl,cr Purccl Nunttkr
t
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(s
4 Il) Pmnluge(Il)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if 'es❑ Municipal❑ On site disposal syxtcm ❑
SECTION2: PROPERTY OWNERSHIP
2.1 Owners o Record:
:TT�hn �i' IPSI ucltFh F�,Iw�l SC, Ie,r� 111� QIG� �
N;mu(Pool) (.uy.State.LIP _
c WC1.1 kr 61-
NO.:vtd Street Telephone Entail Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Detttolition ❑ Accessory Bldg.❑ Numberof Units_ Other ❑ Specify:
Brief DescriptionofProposedWork':
` Itr c t� a-h� �trtil a=1 ;to -I Jar ityinc n^'1
SECTION a: ESTIMATED CONSTRUCTION COSTS
I1t11t Estimated Costs:
(Labur and Materials) Official Use Only
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard City/Tosvn Application Fee
?. Plumbing ❑Total Project Cost't hem 6)x multiplier?. Other Fees: S .x x
_ddJ. \Icch:utical Ili\':1(') S List:_
5. .\Icehanical iFire
`— -- —
Suptrcssionl S Tutul :\If Fees: S
t,. Total Project Cost: S t q co , to Check No, __--('heck:\mount - _-_---Cash:\nnnun: ..
0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(C'SL)
License Numher---- --- j:.\piruion Date
Nante of C'SI. I lulder
List('St.1)pe Isee helowl
---- ------------ "I)pc Description
—
U Unrestricted IlfuilJin s ti to)S,u110 nt. It.l
Restricted 1&2 Family D%wllin II
C itsifoen.State.LlP NI Nlasonry
RC Roolling Cincrin
WS Window and Siding
SF Solid Fact Burning Appliances
I Insulmion
Tek fume Entail address Denurlilion
5.2 Registered Home Improvement Contractor(HIC)
IIIC Registration Number lispiratiun Datu
IIIC C'ompan) Name or IIIC Registrant Name
No. and Street Email address
City/Town.State,ZIP "rele hone
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 7b:OWNERI 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 appli on is true and accurate to the best of my knowledge and understanding.
1'rii Ottncr'a pale urixd Agent's Name 11'.Icctrunie Sign;uure) Date
11 NOTES:
I. An Owner who obtains a building permit to do his,her own work,or an owner who hires an unregistered contractor
inot registered in the Hone Improvement Contractor(HIC) Program),will no have access to the arbitration
program or guaranty fund under M.G.L.c. 1 4'_A.Other important information on the HIC Program can be found at
worn nm,., rs_ ,y.t Information on the Construction Supervisor License can be found at n kkrr.nas�bus dii,
2. When substantial work is planned, provide the information below:
Total floor area isq. R.) _ I including garage, finished bascmcntattics,decks or porch)
(boss living area(sq. R.l " _ Habitable roust count
Number of tireplaces Number of bedrooms
Numher of bathrooms _ _..". . - -- — Number of half Nadu
I,N pc of heating s)stun . . . .. ._ . _. _ Numher of decks, porches
I1pCofCoalingisstem ... Fncloscd
1. "Total Project Square Footage-ma) be substituted ror"Tool Project Cost-
CITY OF SM 0of
PUBLIC PROPERTY
1 10 DEPAR'RIENT
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HOMEOWNER LICLNSB EXE.MMON
P1sw Ftlet
Date
Job Loeadon d
Home owmr Address t , 3
Home Owner Telephone I--) Y -7 N y . .;5
Prcaant Mailing Address A W 0,1 W ice-
The curnat exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units Of leas and to allow such homeowners to engage an individual for
hire who does not possess a licass4 provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Person(s) who owns a parcel of land on which hdsM resides or intends to reside.on
which then is, or is intended to be,a one or two family dwelling, attached or detached
etnsctures 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 Oillcial,on a form acceptable to the Building
Official, that hedshe be responsible for all such work performed under the Building
Permit
The undersigned"homeowner"auumes responsibility for compliance with the State
Building Code and other applicable bylaws and regulations.
The undenigned "homeowner"certifies that helshe understands the City of Salem
Building Department minimum impaction procedures and requirements and that helshe
will comply with said procedures and requirements,
HOMEOWNERS SIGNATURE
T—
.>PPROVAL OF SUILDLUG LNSPECTOR
See other side for state code