12 WHEATLAND ST - BUILDING INSPECTION The Commonwealth of Massachusetts �µ� RECEIVED
Board of Building Regulations and Standar' SPECTIONAL S RVICWY OF
Massachusetts State Building Code, 780 CMR LEM
:•s: " 1 ���p � Revised Mar 2011
Building Permit Application To Construct, Repair, RenovatIM VNHoL% aP 25 '
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name) Signature " Dal
SECTION 1:SITE INFORMATION
1.1 Pr�up@@rty AJJresst o , 1.2 Assessors Map& Parcel Numbers
I� Wr`euf�lihGl` �} Sglerr �f'
I.la Is this an accepted street?yes no Map Number Parccl Number
1.3 'Zoning Information: - — 1.4 Property Dimensions:
Zoning District ProPoScd Use Lot Area(sy 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards 12ear Yard
Required Provided Rcyuired Provide) I2eyuircd Provided
1.6 Water Supply:(iM.G.L e.d0,§54) 1.7 Flood ?.one Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?(:heck if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTYOWNERSIIIPt
2. ,Owner'of R cord:
1 utifwtrn S1irw MVfi Oil �G
N:unc(Print) City,titalc,zll
---+_
1� Wu P_rti� ((A Mk—
No. S't _
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 ❑ 1 Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify:____
Brief Description of Proposed Work'-
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials) Official Use Only
I. Building $ O0. 0J
I. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard Cily/I'own Application Fee
❑Total Project Cost'(Item 6)x multiplier x_ -
3. Plumbing $ 2. Other Fees: $ _
d. Mechanical (1IvAC) .$ List:
TMechanical (Fire Suppression) $ Total All Fees: $_
('heck No.check Amount:_—Cash AmnunC
6. 'Dotal Project Cost $ ❑ Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES C
5.1 Construction Supervisor99Liceppse(CSL)
" ,}1.�`
LJJ
License Number Expiration Date
Namc of CSL Holder O � �,���
G S � � n List CSL"type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35.000 cu. ft.)
R Restricted 1&2 FamilyDwelling
CiN/towq State,ZIP M Mason
ry
RC Rooting Covering
WS Window and Sitting
SF Solid Fuel Burning Appliances
I I Insulation
Telephone Email address D Demolition
5.2 Registered Ho a Impr vem t nQtrac t r(IIIC) /
�' IlIC Registration Number Ex irati n Date
I IIC Company Nanfe or I-IIC Registrant Namc
n � J
No.and Street /U - '�n�I� J� Jr/y� h � /l�
U l (ljt 6 U ll Email address
,' �j
Ci[ /Town, State,ZIP �„ • , "I'cle hone W t 1 �f',LmQ(�.% "C.•, �Q'
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 2 C(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 Issua ce 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
1,as Owner of the subject property,hereby authorize S42s/e— W,Cv
to act on my behalf, in all matters relative to work authorized by this building permit application.
SG OiC KC VLs{rrutM Gi /cl
Print Owners Kane(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 understandin
s« 4 11t-klf"Icar\ (; 7;
Print Owner's or Authorized Agent's Name(Eleetronic Signature) 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(HIC) Program), will not have access to the arbitration
program or guaranty fund under bLG.L. c. 142A.Other important information on the HIC Program can be found at
www.niass.eov/oca Information on the Construction Supervisor License can be found at cvww.mass.gov/dns
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. 11.) Habitable room count_
Number of fireplaces _ Number of bedrooms _
Number of bathrooms Number of halt/baths _
Type of heating system_ Number of decks/porches
I'ypeofcoolingsystem_ Enclosed_ Open
3. "'I"olal Project Square Footage"may be substituted for""total Project Cost'
/ Y
' CLTY OF Siu.EM, NL�SS.ICHUSETTS
- t•
BUILDING DEPARTME-NT
120 WASHNGTON STREET, 3"a FLOOR
TEL (978) 745-9595
FA.x(978) 740-9846
K1MBERLHY DRISCOLL
AAYOR THOMAs STTIF—R RS
DIRECTOR OF PUBLIC PROPERTY/BOLDING COMISSIONER
Workers' Compensation Insurance Attidavit: Builders/Contractors/El ectricians/Plumhers
Applicant Informatinti Please Print Le ibi
Mum: lndivittu:d):
Address: 16 IL. IU.L
City/State/Zip: 0/ 1q 7
Phone tl:
/
Are you an employer'!Check the appropriate box: 'Type f p7addition
1.❑ 1 am a employer with 4. ❑ I am a general contractor and I 6, Newconstruction
�/employees(full and/or pan-time).• have hired the sub-contractors
2.C✓J I on a sole proprietor or partner- listed on the atlachcd sheet. t 7• ❑Rem
ship and have no employees These sub-contractors have d. ❑ Dem
working liar me in any capacity. workers'comp. insurance. 9. ❑ Buil1No workers'comp.insurance 5. ❑ We are a corporation mad its,
required.) officers have exercised their 10.❑ Elecrcarepars or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. (No workers'comp. c. 152, §I(4),and we have no 12.❑ Raof repairs
insurance requited.) t employees. (N'o workers' j},❑Olher
comp. insurance required.]
Any 3rltkva owl cheeks but 01 must also fill uu1 the scdiva below showing their werken'cumparrud n policy inll,rtnation.
;A.
I Iomeuwtsrs,who submit this atndnvii indicating they art doing all work and then hire uutside cuntmeon most mihmit anew afndavit indicting tech.
$'.numcton her chak ihia box mtat.nlaehul an:uldltiuwl ahul showing llw mune of the tubwontnciort and their workent'comp.pulley information.
I ant can eutployer that is pruviding ivorRers'cuntptatsailan.ittrurrotce for my unpluyees. Below is the polky and fob.sire
iu/arnrurion.
Insunmce Company Name: __,_.
policy 4 or Self-inn. Lie. d: Expiration Date: '
Job Site Address: City/State/Zip;
,lttach a copy of the worrten'compensation pulley declaratlan page(showing the policy number and explradon date). ,
F'ailuru to vecuru coverage as required under Section 23A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the farm of a STOP WORK ORDER and a line
of up to s25o.00 a day against file violator. Be advised that a copy of this statement may be forwarded to the OI'lice of
Invcstigmiuns oldie MA for insurance coverage vcri lieatiun.
/do hereby certify 'u et d e paint m d I irs f e ' at the inforraaUau pruvided a/Move r.s rure�uud •orrect
Si�"I. I rc
Phone t 7
OQicial toe only. Du not mite itt this area, to be cutuplefed by city up town njjiciuC
Cityorfawn: _.. .--- Permit/LkenseN__._
Lssuing ,ltilburily (circle one):
L Board cat INahh 2. Iluildlog I)ep.n lutcut ].Cilylfnwn Clerk I. FIectriui Inspector. 5. Plumbing lm cuor
G. Other
Contact 1'ersow _._._.__ Phone 's:
CITY OF 5.1L: Nr2 LYCISSACHUSETTS
/i BL'ILOLYG DEPAR-niE,%r
(20 ` ASJ4LNGTON STREET, 3w FLOOM
T EL (975) 745-9595
KIMBUT EY DRISCOLL FAA(973) 7-W-9344
� "YO;t
I�-lOSC13 ST.PI�gR$
DIRECTOR OFPLBUC PROPERTY/BL'tLDLNG C0JL8,,5S[0NEZ
Construction Debris Disposal A111davit
(required for all demolition and renovation work)
In accordance with the sixth edition Of the State Building Coda, 780 QJR
Debris, and the provisions of tbiGL c 40, S 54; section l l 1.5
Building permit /!this is issued with the condition that the debris resulting &am
l !, S 1 SOA.1 work shall be disposed of in a properly licensed waste disposal facility as defined by SIGL c
1'Itc(lebris will be transported by:
y
y NprcTt4 S Ids CC Y4'h
(name ut'haulur)
The debris will be disposed of in
(rtaritc Or LICI ty)
.—_ --(ad;lre:"Ot rireility/ .
�Z I
--siywrurr ut pa'rnir a r _—
- �; /i 17
CITY OF SALEM, MASSAQ IUSETTS
BUILDING DEPARTNfENT
120 WASHINGTONS'ITfEET,3 FLOOR
. roc TEL. (978) 745-9595
Fr\x(978) 740-9846
KIMBERLEY DRISCOLI
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONLVBSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date
Job Location I W n e a((�nc� S ct I c O i rj
Home Owner Address ,qCt %A—
Present Mailing Address Sa'lyl�
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 ,