29 WINTER ISLAND RD - BUILDING INSPECTION (7) s, _
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 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 Applied: - -
Building Official(Print Name) Signatutf Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
�q Y�Itn�rr zsland /CDa� Oy-00 21- 6
1.1 a Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Cotazt+,at )P 'da,"4te,l 0•1/13a(res
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Sidc 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:
Public Ir Private❑ Zone: Outside Flood Zone? Municipal G31%site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Qwner'of RecoF�dd:
Joao ', 197G
_
Name(Print) Ciry,S State,ZIP
9 l•�,n¢edsl �d q�ss yy999�> tJ sco ffa7 bgc 9 s 0ry
No.and Street Telephone Email Ad Hess O
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work'I:
—llfi ye wa(f -la eon--> rod o .n,o ojwe�e¢ dtnthy roavh can,( C' �e
a kw,tcet1�
q— _
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
I. Building - $ /01 p 0 p 1. Building Permit Fee:S Indicate how fee is detemrined:
2.Electrical $ 00 0 ❑Standard City/Town Application Fee
❑Total Project Cos[ (Item 6)x multiplier x
3.Plumbing $ _ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $ —
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ Pa, 0 0 0 0 Paid in Full 0 Outstanding Balance Due:
t SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu. Pt.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
_ HIC Registration Number - Expiration Date
HIC Company Name or HIC Registrant Narne
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 mud 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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER' Olt AUTHORIZED AGENT DECLARATION
By entering my name below,1 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.
I! /a / 3
Pr' Owner's or Aut orized Agent's Name(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do hislicr 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. Otter important information on the HIC Program can be found at
www.mass.sov/oca Information on the Construction Supervisor License can be found at www.naass.goy/dps
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.ft.) 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 Cost"
CITY OF S.t -ENf
PUBLIC PROPERTY
DEPARTN, (ENT
V QWAA"O#AK "
w.a
S�e w.m.�,-ro,snare• �w.waaow stun of ro
rtL f"L715.111" .F.ut,vs-14964
HOMEOWNER LICLNSS E.XX.Mnjo,V
Pettis Print
Date �l -I a- 13 i�
lob Locadon a9 Gt> A2 L
Rome Owns Addrar -
Fi'oma Owner Telephone _998— /-r/- o
Preaeot Rfailbe Addter■ •w
The current exemption of"Homeowner"war extended to include oemar-occupied
dwellings ottwe Unite or fear and to amw mcb homeownere to engage se individual r
hire who.don not poster a kcn$q provided that the owner acts sosupervisor. or
DEFINITION OF H0?aOWNHA
Peron(s) who owns a paved olland on which hdshe«tides or Intends to residey on
which then it, or is intended to bet, a one or two family dweWn L attached or detached
JWxMres accessory to such use and/or rum s cift yea, A peron who comtructe more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner"sW submit to the Building OQlcial,an a roan acceptable to the Building
Oflldal, that helshe 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 by64awv and regulation
The undenigned "homeowner'certifies that he/she undentands the City of Salem
Building Department minimum inspection proeedura and requirements and that he/she
•viIf comply with raid procedures and requirementL
"O-MEO'A NERS SIGMA M RH
kPPROVAL OF BUILONG INSPECTOR
S<e odhcr side for Stara cod4
t
CITY OF SOU Etii, NWSACHUSETTS
• BUI DNG DEPkRn&NT
ie 130 WASHINGTON STREET,3" FLooR
TEL (978) 745-9595
FAX(978) 740-9846
Kl-,(BERLEY DRISCOLL
MAYOR THo,.I,w ST.PIERRB
DIRECTOR OF PUBLIC PRomt ry/Butl. NG cow i1ssIONER
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
111, S 150A.
The debris will be transported by:
!;J GUPrlha
(name of hauler)
The debris will be disposed of in :
n v i 1e ev �(� _
(name of facility)
:14 AGLWj�se f7 6 dc-
(address of facility)
gnature of permit applicant
date
dabdsatl'.ilut: