12 WOODBURY CT - BUILDING INSPECTION -9
3 I Th Board
C•onun fonwealth o Massachusetts
i, ,� of Building Regulations and Standards CITY OF
Massachusetts sy sachusetts State Building Code. 780 C NIR 2011 V SALEM
'L,•• Revised I Lu•Building Permil Application To Construct, Repair. Renovate Or Denwlish a
I One-or Two-Fanol.v Dhrellin,p
This Section For 011icial Use Only
Building Permit Number: Ap
t uii ing Olticial(Print N:unc) Sign• Date
SECTION I:SITE INFORMATION
r
Property A Jrna: 1.2 Assessors blap Sl Parcel Numbers
t1. wuo�P,x! ctz� -r,b �
�a a Is this an acce ted street? -es no bap Number Parcel Numinr
Zoning Information: 1.4 Property Dimenslorm Z
Zoning District Proposed the Lot Area(sq R) Fronlage(II)
1.1 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: 1M.G.1.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Cl Prk ate❑ Zone: _ Outside Flood Zone? Municipal O On site disposal a ,tun ❑
Check if csO P W >:
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownert of Record: 'a
L,FA.p 5
7. LLc- ?CMD91) N9 Q14fn0
N;une(Print) (ny.Slalc.ZIP
10
No.and Steer -relephone Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ O vrici )ccupied 117 Repairsls) O I Alteration(s) O Addition ❑
Demolition C) 1 Accessory Bldg. ❑ 1 Number of Units_ I Other O Specify:
Brief Description of Proposed Work": towLIf ,fl ) Yoro•
SECTION J: ESTIMATED CONSTRUCTION COSTS
Items Estimated Costs:
I(.abor and .\I:nerialsl Official Use Only
1. Building S I. Building Permit Fee: f Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(hem 6)x multiplier her _ x
j 7. Plumbing S 1
_. Other Fees: S
J. Mechanical ill\'.\('I S List:
5. Mechanic:d
ti uppreisiunl S Total .\II Fees: S_ --__ - ---- .._----_ .
I.. Total Project Cos#: S ('heck No. _('heck :\mount: __ ("Ish \niounc
100 OOD.ab ❑ Pail in Full ❑Outstanding Ilal.mce Due;
CALL rhAeh
f�r� - 9oa - 8S3D,
SEC110141 5! ('01SISI'MicrION SERVICES
r.,,I ('onstructioli Supervisor License(C'Si.) \pirati011 Date
ic�nse Number
l`r,iq,JVL_-J);eN
N.1111e 11,(S1, I loldcr I ist CSI. 1)PC I'doo)
PC DescriptionJ,', d Stre
et (i 035.om)
-R Ri:.,triclt:d 1&2 1 Milk 2"ell'oCigi Fotw.State.LIP
ll
\l;lsonry
RC Rttolllut Co%enng
WS Windo\% and Sid",
SF Solid Feel Darning Appliances
Insulation
lh a n
Finailaddre%s I
Ibona
on
5.2 Registered 11ortle Improvement Contractor(HIC)
I IIC�Ijcglgrllton Nkunhcr I \111ration,wit:
!I IC'Co-
,opan) Name or I 11C Itogistrant Njilla:
inuil address
No. and Street
rele one
Cl TITO;;,slate,ZIP SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M,G.L C. 152.9 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 .MA..;,Attached? yes ..........Cl No...........13
Si 5MRIUM OWNER AUTHORIZATION ToBE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERN�11T
1, as owner of the subject property,hereby authorize rA
to act on my behalf,in all matters relative to work authorized by this building permit application.
�Date
(Electronic Signature)
SECTIONOWNERI On AUTHORIZED IVL[nRIZED AGENT DECLARATION
of perjury that all of the information
By enterin my name below,I hereby attest under the pains and penalties
colitaine' 'i this ap 10 1 rue,and.accurate to the best or my knowledge and understanding.
J,Q
n/ DuW
Pri,
;NOTES:
---i771,1 0%,tiler \t,hu obtains a building permit to do his her own work,or an owner who hires an unregistered contractor
(lot registered in the Hollit 1111provellient Contractor(HIC) Program),will Luj) have access to the arbitration
program ur guaranty fund under M.G.L. c. 142A.Other important information on the HIC program can be found at
�O+ "I I Information on the Construction Supervisor License can be round aitt,%k,,
ulawntial work is planned, provide tilt information below:
'en I including garige. finished bascinent.ittics,Jocks kit porch)
ll',or area(Nq. ft.)
2 \\ It ow Moor
Habitable room count
(Or"'s,tiling area i s4. 11 Number ol'bedrooms
\mllber of 11replacci ... Number ofliall'ball's at-
Numher,ii bathrooms -,oinhq:r%)fdxks, lior,;Iies
I lu:of IWAting S%iwill V%lil, Flldoscd Opelt
I lie"I%:t1t,111111 S%itetill 1,14
Ill proj"t StImire oh.stituted liar total Projed Cost" 11
CITY OF S.UZ%f, .tiL1SS.ICHL'SETTS `
13LLLDLNG OEP.gAT% F,\T
120 WASHNGTON STREar, J0 ftmt
T ?L (978) 745-959S
Kl.%c3F tL RY ORMOLL FAX(978) 740.9946
MAYOR THosw ST.PMUS
DIRSC1701<OP PLOLtc P1t0PERTY/gt:m0L/G CONNISSIONER
Construction Debris Ddsposal AdIdavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CM
Debris, and the provisions of MGL a 40, S .14; R section i l I.3
11 Building Permit 1* is issued with the condition that the debris resulting from
work shell be disposed of in a pro
1 11, S I SOA. perly licensed waste disposal racility as defined by NIGL c
The debris will be transported by:
(M:un ufhha lar)
The debris will be disposed of in
J�NI
Wdress of sail, )
uynaMNro pecmrt 119PIcmIt
,1,�t
CITY OF SAi..E.Ni
PUBLIC PROPERTY
DEPARni. LENT
U 10�atar n�r.yw
Vw.a@ t b vawm�a!rust.s�ua�wa�oarars flH-s
HOMEOWNER LICLNS6 EXEMMON
P1eew Frlat
~ lob Location 12 w oo)i3-DVY C-7-
Home Owner Addrw /3 L ,-,v c_fl sT
Hom owoerTelepbooe 61 -, :�jaa
Present Mailing Address s asno
The current exemption of"Homeowne a was extended to inchtde owner-occupied
dwellings of two Units at leas and to allow such homeowners to engages an individual for
hire who does not possess;a licensed provided tbA the owner acts as supervisor.
DF27N 'I'ION 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 be6 a one or two family dwelling attached or detached
structured accessory to such use and/or farm structure. 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 Odleial,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 understands the City of Salem
Building Department minimum inspecti procedur equirements and that he/she
Mill comply with said procedures and emen
HOMEOWNERS SIGNATURE
,VPROVAL OF SUILDLVG NSPEC70
See other side for state code
0