2 WOODSIDE ST - BUILDING INSPECTION (2) 713) y - 1
\� The Commonwealth of Massachusetts
� Board of Building Regulations and Standards CITY OF
\ b(( Massachusetts State Building Code, 780 CNIR SALEM
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised;Nnr2011
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number:
i Date.Applied
Building ORicial(Print Name). / �p
Signature Dat
]A Property Address:
SECTION I SITE►NFORt�fA ON
ujog fac SF 1.2 Assessors 61ap&Parcel Numbers
I.la Is this an accepted street?yes_ no Map Number
Parcel Number
1.3 'Lotting Information: IA Property Dimensions:
Zoning District Proposed Use
Lot Area(sq 11) Prontage(R)
LS Building Setbacks(ft)
Front Yard Side Yards
Provided Required Required Provide) Rear Yard
Required wired
q Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check ifyes❑ Municipal❑ On site disposal system ❑
2.1 Owner'of Recur SECTION 2: PROPERTY OWNERSHIP'
d:
tP uny
(�\/ City,State,ZIP
No.mtd Street
Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner•Occupied ❑ Repairs(s) ❑ Altemtic n(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units
Brief Description of Proposed Work': Other ❑ Specify:
r �
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Nlaterfals) Official Use Only
I. Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
3. Plumbing ❑Total Project Costa(Item 6)x multiplier x
2. Other Fees: S
4. Wchanical (HVAC) S List: ����
5. Mechanical (Fire `l t✓C/
Su ression) S Total All Fees:S
6. Total Project Cult S y �dQ Check No._Check Amount: Cash Amount:_
❑ Paid in Full ❑Outstanding Balance Due:
,
I
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) License Nun Expiration
Name of CSL Holder List CSL'rype(se below)'type -... Description .
No.and Street U Unrestricted ijaindin s a -to 35,000 cu. tl I
itRestricted 1&2 Panil Dwelling
M Mason
Clty/Tuwn,State,ZIP RC Roofin Coverm
WS Window and Sidin
SF Solid Fuel Burning Appliances
I Insulation
mail address D Demolition
E
Tele hone
5.2 egistered Home Improvement Contractor(HIC)
R -- Registration rati— o— n— Number Expiration'Date
HIC Compaty Name or HIC Registrant Name
Emuil address
No.and Street
Tele hone -
Cit Town,State,ZIP
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c, 152.¢ 2?C(
itted with this application. Failure to provide
Workers Compensation Insurance affidavit must be completed and subm
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .....ER❑
No........... ❑
SECTION 7a:OWNER�l1THORiZATION.TO BE COMPLETED PERM:
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,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.
Date
Print owner's Name(Electronic Signature)
SECTION 7b:OWNER'OR AUTHORIZ ATION
ED AGENT DECLAR
By entering my name below,I hereby,attest under the pains and penalties of perjury that all of the information
Xcontained in this application is true and accurate to the best of my knowledge and understanding.
( eli�j JC o S S Dale Y
Print Ow er's or Authorized Agent's Numo(Eleclronie Signaulre)
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(FIIC) Program),will nut have access to the arbitration
rtant
ormation on the
,k%v%v nn o,',"y'0ca Information tilon on he Construction O Supervisor r License can be found at%P w.1113 rogram c O lj's at
rk is planned,provide the information below: basement/attics,decks or porch)
2. When substantial wo p (including garage,finished basemen
'total floor area(sq. RJ Habitable room count
Gross living area(sq. ftJ__.—.------- Number of bedrooms
Number of fireplaces Number of half/baths
Number of bathrooms Number of decks/porches�—
TYpe of hcatingsystem Enclosed —
Open
Type orcooling system
3. "Total Project Square Footage"nnay be substituted for"Total Project Cost"
QTY OF SALEM, MASSACHUSETTS
fl BUILDING DEPARTMENT
120 WASHNGTON STREET,3R11 FLOOR
TEL. (978) 745-9595
FAx(978) 740-9846
KIMBERLEY DRISCOLL
MAYOR THomAs STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMNIISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date / — / 6 — `�a7/
Job Location wn oc),o 5Yo�'
Home Owner Address
Present Mailing Address
The current exemption of"Homeowners" was extended to include owner-occupied dwellings of two
Units or less and to allow such homeowners to engage an individual for hire that does not possess a
license, provided that the owner acts as supervisor.
DEFINITION 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 be, a one-or two-family dwelling, attached or detached structures accessory to such use
and/or farm structures. 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 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 understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR
�1
JiU E.1rt, ti�:1SSACHUSETIS
CITY OF
"N. BUILDING DEPARTJI.&NT
t 130 WASHLYGTON STREET, )"m FLOOR
•� Y";'' T EL (978) 745-9595
Kl11BERI EY DRISCOLL FAM(978) 740-9844
NLAY01 TkOSLU ST.PIEARB
DIRECTOR OF PUBLIC PROPERTY/BUmj=NG co\12MISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5
Debris, and the provisions of NiGL c 40, S 54;
Building Permit k 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 b1GL c
l 11, S I50A.
['he debris will be transported by:
ti
(name ofhauler)
The debris will be disposed of in
-- - (narne of tacdity)
(address or facility)
signature or permit applicant
laic