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10 WARNER ST - BUILDING INSPECTION / X the Commonwealth of Massachusetts n '(t 119 Board of Building Regulations and Standar ECEIyEO CITY OF Massachusetts State Building Code, 780 SALEM �NSp IONAL SERYIC Revi.sedMor2011 Building Permit Application To Construct, Repair, enovate Or Demolish as ,O One-or Two-ramily Dwelling 2 4 This Section For Official Use Mnly Building Permit Number: gay Applied: s z 1 Building Official(Print Name) Sigm '— t? e SECTION 1:SITE INFORMATION Li Property Ad� 2�dress: S1' �./1�7 /rl 1.2 Assessors Map& Parcel Numbers /d (,fJQ Y �i I.I a Is this an accepted street?yes_ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq(1) Fronmge(11) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Iequired Provided Required Provided 1.6 Water Supply:(M.G.I,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: "Lone: _ Outside Flood Zone'? Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner of Record: Name(Print) City,Slate,ZIP If No.and Strect /Q Q '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': Ku�R/ 5 5 SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building $ I. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S 4. Mechanical (FIVAC) $ List: 5. Mechanical (Fire $ Su ression) Total All Fees:$ Check No. Check Amount: Cash Amount: Yy� 6. Total Project Cost: $ 0.1"/6 pp, p ❑ paid in Full ❑Outstanding Balance Due: LA i� SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) r ? , • '�).3�� License Number Expiration Date Name of CSL Holder ""t' r.. 2k1 List CSL'1'ype(see below) 0 . !U n _ No.and Street a 1 r411 9(!K TYPe Description , U Unrestricted(Buildings up to 35,000 cu. ft.) R Restricted 1&2 Family Dwelling Citylrown,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 1 I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date IIIC 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. § 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...........0 SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, 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: 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. X -2EV [/a A G" ue z 71 Print Owner's or Authorized gent's Name(Electra c Si alure) Date 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(FIIC)Program), will not 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 www.nutss.Qov/oca Information on the Construction Supervisor License can be found at www.nmss.sov/dos 2. When substantial work is planned,provide the information below: Total floor area(sq. ft.) (including garage, finished basement/attics,decks or porch) Gross living area(sq. R.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of halbbaths Type of heating system_ _ Number of decks/porches Type ofcoolingsystem Enclosed Open_ ;. "Total Project Square Footage"may be substituted for"Total Project Cost' y �< CITY OF SALEM, MASSACHUSETTS ` !) BUILDING DEPARTMENT y �e 120 WASHNGTON STREET,3'FLOOR TEL. (978) 745-9595 FAX(978) 740-9846 KINIBERLEY DRISCOLL MAYOR THOMAS STTIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: 1 Date Job Locationl0 LIJQ l hQ S 7 .Sa�IC�� Home Owner Address Goa I'1) e y 5 L7 O/ `f' ) z) Present Mailing Address Al lea {VM �I^ Sf—��m Intl e-y The current exemption of"Homeowners" was extended to include owner-occupied dwellings of two Units or less and to allow such homeowners to engage an individual for hire that does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER 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 "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 "homeowner" assumes responsibility for compliance with the State Building Code and other applicable by-laws and regulations. The undersigned "homeowner" certifies that he/she understand the City of Salem Building Department minimum inspection procedures and requirements and that he/she will comply with such procedures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING INSPECTOR CITY OE S.1LE1 t, L%l;1SS:ICHUSETTS t ©L=LNG DEPAR-M NT 120 WASHLNGT 'O ON STREET, 3 FLOOR TEL (973) 745-9595 F,ux(978) 7-10-9845 K11tBEltLcY DRISCOLL ANLAYO,'t Tmo.4 LAB ST.PtiaRB Dt7ECfOR OF PusLic PROPERTY/SLILDLNG CONNISSIONER Construction Debris Disposal At'tldavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 CDJR section 111.5 Debris, and the provisions of NIM c 40, S 54; Building Permit tl is issued with the condition that the debris resulting from l l 1, S i SOA. this work shall be disposed of in a properly licensed waste disposal facility as defined by 14IGL c The debris will be transported by: i y lUo2 SAD Y2 Ca Y�7 kl (name ut'Itauler) The debris will be disposed of in (narne oe taulity) (adJrcss ol'rStility) 51 yrI1rU(p p(�;`RII(,1 f7(Il'dll[ s�� / 0-,� IX,