1 WINTER ISLAND RD - BUILDING INSPECTION (3) �1' °� - - ---- --
The Commonwealth of Massachusetts CITY OF
'i•i Board of Building Regulations and Standards SALEM
{,u Massachusetts State Building Code, 780 CMR 1levised.tlur2011
L.
Building Permit Application To Construct, Repair, Renovate Or D o is
One-or Two-Family Duelling
This Section For Official Use Oid
Building Pennit Number: to Applied:
/ /y l
Uui g 011icial(Print N;une) Signature Uate
SECTION 1: SITE INFORMAT
I Property Address: 1.2 Assessors Map Sr Parcel Numbers
1 I I A ) 1 S.c�Ct✓t�z�f`G1 —
L 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 It) Frontage(tl)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
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:
Zone: _ Outside Flood Zone?
P "Iic❑ Private❑ Check ifyes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROP RTY OWNERSHIP'
2.1 Owner of Record: /) l� F) 0
1Q ry
.S I! o _j 1
;ane(Pring _ City.State.ZIP
1 lJtn�er �loa,cl fid• (� �1g �4I- �5 '� 7
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION ROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ wner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':_c- -ha1 a x
SECTION 4: ESTINIATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and \laterials 1
I. Building S I. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
'_. Electrical S ❑Total Project Cost'(Item 6)x multiplier x—T
3. Plumbing S ?. Other Fees: S
4. Mechanical (IIVAC) S List:
5. .\Iechanieal (Fire $ Total All Fees: S
S u t�ress ion 1
Check No. _Check Amount: __Cash :\mount:_—--
6. Total Project Cult: 5 L}.r 000 0 Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
__ License Number licpir:nion Dam
Name o(C'SL. I IulJcr
List CSI- Type(see below)
Nu, :aJ Slrcct Type Description
U unrestricted(Buildings tio to 35,000 cu. Il.)
City/town,Sl:nc.ZIP -- R Restricted M2 Fannil Dwcllill
M Mown
I Ruofin C'uverin
WS Window and Sidin
SF Solid Fuel Burning Appliances
I Insulation
Tele hone Email address I) Demolition
5.2 Registered Home Improvement Contractor(HIC)
IIIC Camnpuny Name or I11C Registrant Name
IIIC Registration Number liapir tion Date
No. and Street
Email address
Ci /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...........❑
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.
Not Owner's Name(Electronic Signature) Dale
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
coma' in this application is true and accurate to the best of my knowledge and understanding.
J �u
Print
Owner s or A.uthonzeJ Agent s Name 1I�.Iccuunic.Sign:(ure) 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
Pro
or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
t1)s t5:!fit!s3..gyg nc;i Information on the it
Supervisor License can be found at ggr�:nias:.mot 'JI1;
2 When substantial work is planned,provide the information below:
Total fluor area(sq. B.) (including garage, finished basement'attics,decks or Porch)
Gross living area(sq. It.) _— Habitable room count
Number oftircplaces- -_-- Nunnberofbedroonts ---
NLill)her of bathrooms --- ----------
---_--___ Number of halfb:ohs
1)pe of heating system _
Nuntberufdecks, porches..
l)pe of couGe nss stent --- ----------
_ .__. __.__..--------._-_ Inclosed Open
t Total Project Square Footage"ntay be Substituted fir"fatal Project Cuss"
Cin of S.1 .&M. AAss iCHUSETTs
OLMDLNG DEPARTIENT
110 W.kiHLVGTON STREET, Y°FCOOR
T8L (978) 74S.9599
}t FAX(978) 7449&16
WJ®t.AL.EY DIUSCOLL
MAYOR T}iouU ST.PMx"
DIRELTOR OP PLBLIc PROPERTV/9t: DLNG c0\pIIs5I0V ER
Construction Debris Disposal At'ttdavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit p is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility) v
(Iddreaa or'facihty)
eiynamrc ofpermit appapica (�
C/
Ltr
CITY OF S.U.EM
PUBLIC PROPERTY
DEPARTMENT
wotatt,Y ouamtL
�j V'""Oa �]t1 v.our�c�aM ln.er to su,,w ww�nRur,s oN-e
Y rM 9'5-745.91"•FAX 93,740.964
HOMEOWNER LICLNSS EXE.ti[PTION
Please "I
Date ID- 14- 11
Job Location I U) I n�e t �s1 cox( `Rc'
Home Owm Address Ii) I n-6,r -Xslrtncl 2al
Home Owner Telephnes - q S y-1
Present Mailiag Address 1 j ,n la r
hr
The cummt exemption o["Homeowners"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 poness a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Pawn(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 dweWng, attached or detached
structures accessory to such we and/or farm sWxturea. 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
Oil9cial, that WAS 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 reguladonL
The undenigned "homeowner certifies " 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 SIGNAMME �I' '
APPROVAL OF SUILDNG NSPECTOR ,J
See other side for state coda
9