1 WINTER ISLAND RD - BUILDING INSPECTION (2) . , --F'� c�! � � a 3v '
' � � 3o�•G` �L����s �
� The Commonwealth of Massacl�usetts
,\� o Board of Building Regulations and Standards CITY OF I
IV ,-� Massachusetts State Building Code, 780 CMR SALEM
O Revised Mar 2011
I Building Permit Application To Construct,Repair, Renovate Or Demolish a
One- or Two-Family Dwelling
. . _ �� ,
`Chis Sechon For bfficial Use Q
Bu�ldmg Permit Number. Date 'e
� ' �
� � K,: :
, �� , `_ , ��, ;
Bui�cial(PrintNam�� � =--� F, „ 'S gnatur �, - DaYe � �
� :` ` ��SECTION 1: SITE FNFORMi�TION. ��,'� ,,.. ;� �';., �� �. � � .
1.1 Property Address: �� �� � 1.2 Assessors Map&Parcel Numbers
1 c�� �,!�,- I^�l��d f�d.
11 a Is this an accepYed sVeet?yes no Map Number Parcel Number
1.3 Zoning I�formation: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(8)
1.5 Building Setbacks(ft)
� Front Yard Side Yazds Rear Yazd
� Required Provided Required Provided Required Provided -
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Ouiside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
_,,. v . . .�_ .:. ._„- ° -.--
. SECTION 2i�PROPEItTY,OWNP+RSHIP � �"
1 - �.
21 Qwner�of R cord: " , ,
lFot-ivii �C.�v1610.T�6S J�1'�' , /"� 1-1 � � a � �
Name(Print) � City, State,ZIP
�. 1.1� �n �J-s��d�E�d, q"I� '1 '-� � - 7�S`f�
No.and Street Telephone Email Address
SECTLON 3:'DESCRIPTION�OF PROPOSED WORK�(check all that apply) �
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Altzration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
��ief Descriptio of Proposed Worl�:
-�,r,� �.1< �ax i � , s;n,al�Q ,, ��1< ,�. � c� x �
� , �SECTION 4:ESTIMATED CONSTRUCTION COSTS n h x��� .,_, .
Estimated Costs: c � �" � �; i
'� Offictal Use Only I
Item Labor and Materials ' °; z :� p �r= � � � �_ -, �
1.Building $ 1 BuildLag Permit�ee $ - aindicafehow fee is determined: _
❑ Standacd City/ToivnApplicationFee x. �
2.Electrical $ � �p Tota�Project Cos�'(Item 6)Xraultipliei � x'�
3. Plumbing $ 2`�Odzez-E'ees $ � � �� "� �' �` �
� T ����� ,.
4.Mechanical (HVAC) $ List � � � - ' * 3
,� , .
5.Mechanical (Fire " " � � "
Su ression $ Total P.11�Fees $` a r>�� � �,� '�' ,� �: n�
�� Gheck No #,Check Amount ��� ?=Cash Amount: '. � �
6. Total Project Cost � g� (�Q� „p Paicl id Fhll ���� O OutstancluigBalance Due:
� ��.�-tL �o ��-' 4�-''�--L�
I� �
,: . _. . , ,r,�.. . .., ..� -... .�_ �- — . . .
��, � � SEC`PION 5: �CONSTRUCTION S�i�2VICES,4 , „�»,�� ;;, ,
��- � . < <.,�, � � � _
51 Construction Supervisor License(CSL)
License Number Expiration Date
� Name of CSL Holder
List CSL Type(see below)
No. and StreeC " 'sTy�p�' �s �'�:`"'^� ;�.u.f Descnption'S;,„,,- �s � '��
U� Unrestricted Buildin s u to 35,000 cu. ft. �
R Restricted I&2Fami1 Dwellin
Ciry/Towq State,ZIP , M Masonry
' RC Roofin Coverin
WS Window and Sidin
SF Solid Fuel Buming Appliances
I [nsulation
Tele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC RegisVa[ion Number Expiration Date
HIC Company Name or HIC Registrant Name
No. and Street Email address
Ci /Town,State,ZIP Tele hone
SECTION'6;,WORI{ERS' COMPENSATION INSURANCE AFFIDAViT(M G L:.e. 152. § 25C(6)) K
� >
. re_. . _ . . . . - b.: ��
.�. ..� �v. .X ��' ca�Wn.,. a.�r o� = ,. v ..,� .: � a
Workers Compensation Insurance a�davit 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........... ❑
, :������ '� ��'�SEC�TION 7a: OWNER AUTI30RIZ�ITION TO,B�COMPI:�TED Wi1�N ��" � '
: OWNER'S AGENT;OR CONTRACTOFi APP-I.IES FOR BT7ILDING PEI2MIT;` ;
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(ElecVonic Signature) Date
'° SECT�bN 7b: OWNER' OR`AUTHORIZ�D AGENT DECLARATIQN,� , x.' ��;, -:�
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contai�s application is true and accurate to the best of my knowledge and understanding.
�'- q -la.
Print Owner's or Authorized AgenYs ame(Electronic Signature) Date
4 �,NOTES �' � ��� �f �� - �:.�
1. 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 M.G.L. c. 142A. Other unportant information on the HIC Program can be found at
wcvw.mass. o�Information on the Construction Supervisor License can be found at w��w.mass.govid�s
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including gazage,finished basemenUattics,decks or porch)
Gross living area(sq. fr.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project CosY'
u.auuaroura,u
Vwroe
Pkass Telco
CITY OF S.UX.N(
PUBLIC PROPERTY
DEPARTitENT
uta. s-&rus»s • r..: r. ta+o.esw
HOMEOWNER LICLNSB EXEM"101
Dategg -�
Job Lacadas LJ, n —�— s I o.m of ROJ
Home Owner Telepha
Present Mailing Addrn
The current exemption of "Homeowner" was extended to include owner -occupied
dwellings of two Unita or leas and to allow such homeowners to engage an individual for
hire who. daft not possess a licenog provided that the owner acts n supervisor.
DEFINITION OF HOhMOWNER
Persons) who owns a parcel of lard on which ha✓she resides or intends to resider on
which then is, or is intended to bur a one or two family dwelling, attached or detached
stnsctures accessory to such use and/or farm structuna A person who construct@ more
than one home in a two year period shall not be considered a homeowner. Such
--homeowner" shall submit to the Building Oilleial, on a form acceptable to the Building
Official, that holshe 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 undersigned "homeowner' certiRa that helshe understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
mill comply with said procedures and requirements
HOMEOWNERS SIGNATURE J' ounce bs
.APPROVAL OF BUILDING DiSPECTOR
See other side for stile code
PROPOSED
EXPANSION
5'x7'
8 \ co
Assessor's Map 44
Lot 16 70
PROPOSED
ADDITION
N
e 1
Assessor's Map 44
Lot 15
Area =
J,900 S.F. f
No.1
2 Story
v� Wood
Dwelling
6, 5,
C.1
xi 7,' 4oi
h x 70 Assessors Map 44
Lot 18
PROPOSED
DECK
�S \
9 41 4
11, O 4
q O
i
Zoning District: R-1
Deed Reference: Book 26237, Page 561
Assessor's Map 44, Lot 17
Proposed Lot Coverage = 30% t
Note: This plan was prepared from a tape survey
and is intended for building inspector purposes only.
Offsets shown on or scaled from this plan are
approximate only and should not be used to determine
property lines.
PLOT PLAN OF LAND
SALEM, MA.
PREPARED FOR
FOTINI MANOLAKOS
> WINTER ISLAND ROAD
SC4LE:1'=20' DATE: NOVEl1DER 15, 2011
DATE. AUGUST 8, 2012
DAVID P. TERENZONI, P.L.S.
4 ALLEN ROAD, PEABODY, MA. 01960
P11-107
CITY of sm Ems Akss.ICHUSETTS
dumow OEF.m-niE\T
1 '0 WASIPINGTON STXM, 1" FZ.00R
. 1t1. X978) 74l�959i
U 1(B F A F AY O UXOLL FAX (978) 1447846
MAYOR momO ST. FMXnsl
D IMTO4 OP PL ELIC PROPERTY13L mDGYG CO.A01ISSION e n
Construction Debris Disposal Atfidavit
(required for Ill demolition and renovation work)
rn accordance with the sixth edition Oahe State Building Code, 780 CMR section 11 I. J
Debris, and the provisions of MCL a 40, 9 34;
Building Permit b is issued with the condition that this debris resulting from
INS work shall be disposed of in a properly licemed waste disposal facility as defined by NIGL o
111, S I JOA.
The debris will be transported by:
VUt (14meul'hauler)
The debris will be disposed of in :
(name Of raudily)
Sc� C�mt IQ �n i� S"JYY
f�ddreu olf�cihry)
J.9,20Q I -V)6& 4-,�
u�n�mre of�ermit applicant
.!are
.,f