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5 WINTER ISLAND RD - BUILDING INSPECTION (3) The Commonwealth of Massachusetts CITY OF �- Board of Building Regulations and Standards SALEM p 80 Massachusetts State Building Code, 7 CNIR 4� Revised.L/ar 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only . Building Permit Number: Date Ap ed: /O Building ORIcial(Print Name). Signature- - Date SECTION I:SITE INFORNIATION AA Property Address: 1.2 Assessors Nlap& Parcel Numbers 4fi k�inLcc Gs �err� �• 1.1 a Is this an accepted street?yes ✓ no Map Number Parcel Number 1.3 Zoning Information: IA Property Dimensions: Zoning District Proposed Use Lot Area(sq 11) Frontage(11) 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? Public Private❑ Check ifyes❑ Municipal AOn site disposal system ❑ SECTION2: PROPERTY OWNERSHIP' 2.1 Ow r crt of Record: p f ine(Print) _ City,State,ZIP ��i rr do r h lard Ye/ %7�95�S�D�Ud in 6�l�iu vve'[�Corue<+ No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply) New Construction ❑ Existing Building I Owner-Occupied Repairs(s) Je I Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': SECTION 4: ESTIbIATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials) I Building ,S I. Building Permit Fee:S Indicate how fee is determined: ❑Standard City/Town Application Fee 3. Electrical .S ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S 1. Other Fees: S 4. Mechanical (FIVAC) S List: 5. Mechanical (Fire S Su ressiun) Total All Fees:S Check No._Check Amount: Cash Amount:_ 6. Total Project Cost: S DDU.v`v ❑ Paid in Full ❑Outstanding Balance Due: (�J emu- 9 =1Ltu-0I00 5 SECTIONS: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder List CSL'fype(see below) No. and Street Type Description , U Unrestricted(Buildings tip to 35,000 cu. It.) R Restricted 1&2 Family Dwelling City/Gown,Slate,ZIP Ni Nfisonry RC Rooting Covering WS Window and Siding SF Solid Fuel Burning Appliances f Insulation Tole hone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date I IIC Company Name or HIC Registrant Name No.and Street Email address City/Town, State,ZIP "fete hone 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...........X 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 t9 act on my behalf, in all matters relative to work authorized by this building permit application. Print Owner's None(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 diin/this application is true and accurate to the best of my knowledge and understanding. Print Own•r's or Authorized Agent's Name(Electronic 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 Flome Improvement Contractor(HIC)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.mass.�,ov'oca Information on the Construction Supervisor License can be found at Www.ntase.^ov!dnS 2. When substantial work is planned,provide the information below: Total floor area(sq. ftJ (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 Ralf/baths Type of healing system Number of decks/porches Type of cooling system Enclosed Open t. "rotal Project Square Footage"may be substituted for"Total Project Cost" r 04, CITY OF SALEM NbsSACHUSETTS ©UILDL\G DEPARTMENT 130 WASHNGTON STREET, 3AD FLOOR a' TLL (978) 745-9595 FAX(978) 740.9846 KI.-,iBERLEY DRISCOLL N AYOR THo.%w ST.PIERRB DIRECTOR OF PUBLIC PROPERTY/BUILDLNG COSWISSIONER Construction Debris Disposal Affidavit (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 # 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 I 11, S 150A. The debris will be transported by: (name Of uler) The debris will be disposed of in : I --- -- S ` f Fi ----- (name o of Faclity) (address of facility) -ignature of permit applicant /'f9 f /lam date l f CITY OF sm Em PUBLIC PROPERTY DEPARTMENT u I uaun 04du" ' Vwrae HOMEOWNER LICLNSE E.XI.Mnjo,*4 Ptsese PHat Due /%%%3 lob Loeadoe Koine Owaes Addkese �a y Home Owoss Telepbow_� 7 —D!or Present Mail[ag Addreee rn The current exemption of"Homeowners"was eatendrad to include-0w nor ocer7ed " dwelihip of hm Units or[ear and to allow mch homeowners to��ateirtdividuai for hire who gene not poaseea a Itcensq provided these the owner acts me aupwWxr. DERNMON 01 H0Aa0WNEII Peraon(s) who owns a pared of Lad on which Wshe r asides or latends to reside,an which then 14 or Is intended to bs; a am or two [!tinny dwOl&& attached or detached structures accessory to such use and/or rum sWxft rest, A pin who consttnxts more Ulan one home in a two year period shalt'not be considered a homeowner. Such "homeownd'shsil submit to the Building OQlcisl,an a forte acceptable ro the Building O/l'Icial, that hdshe be responsible for all such work performed under the Building PermiR The undeni fried "hamaownd'vaumes responsibility for compliance with the State Building Code and other applicable byNlaws and retttladom Tl a undenigted"'homeowner''<erdfles that hdshe undentands the City Of Salem Building Department minimum inspection procedures and requirements and that he/she -vill comply with raid procedures and requirements HOMEVA HERS S[G:JA FL," .iPPROVAL OF ME [INSPECT R S<e uthcr lids for state cods