11D RUSSELL DRIVE B- 950-12 \
Hic C'onunonweallh of Massachusetts
1' Board of Building Regulations and Standards CI VY OF \,; SALENI
lssac( husctts State Building Code. 780 C NIR /lrri.na/ Ilia.'n//
>,
Building Permit t pplirltion To Construct, Repair. Renovate Or Demolish a
(Ate-or TnvFuntih Dmcllitig,
This Section Fur 01)1 se only
Building Permit Number. Dat .\pplied:
Building Otl,cial(Print N; ne) Signature Dale
SECTION I:SITE INFORMATION 101,
1.1 Property Address: 11 D RUSSELL DRIVE 1.2 Assessors Slap do Par Numben
I.la Is this an accepted street? 'es no \Inp Number "reel
Number
I.J Zoning Information: 1.4 Property Dlmenslonu
tuning District Proposed Usc Lot Area(sq IT)- Frontage(ll)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required provided
1.61Vxter Supply:(M.G.I. Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Outside
if cs❑ide Flood Lone? Municipal❑ On site Jisposul system ❑
SECTION2: PROPERTY OWNERSHIP!
Ownert of Record::
a
Name(Pnn City.Slate.LIP
NZ04P _ s,i, n 7S 7y 3 d'PitfC/2 r^ <<
No.:mJ Street Telephone Emuil ABdress
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner•Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ I Addition ❑
Demolition Cl FAccesiory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Vork':
C e
SECTION 4: ESTIMAT `CONSTRUCT-ON COS S
hcm Eslintated Costs:
II.abu r; id\laterials) Ofllclal Use Only
I. Building S rJS p o I. Building Permit Fee: T Indicate how fee is determined:
'_. Flectrical S ❑Standard CitytTussn Application Fee
❑Total Project Cost t(Item On multiplier
1. 111unhing S 1. Other Fees: T_
J. \Irch.mic.tl ill\'.\('1 S List:.
t. \Iv:haniaal IFirc
Su ucssionl T rural \11 Fees: T_
Check No. ('heck Amount: l',hh \monmt:
n Total Project Crest: T 5 Q - ---
❑Pail in Full l 0 Uutst:utJing Ilulmtcc Due:
SEC CON 5: CONNFRIlurION SERVICES
5.1 ('onstruclioliSul)enisur License((SI.)
isee licknO
'I')PC Description
No aid Street I ( nNstriocd(Iluilditi.s ki to 35.000 01 111
It lic'Irivivd I&I F'1111il Dsscllin
Citsi ...... NI Mason
KC Itimlin Ctpvcrin
it,S Window wind sidin
SF Solid I-'Ugl Ilaniing \PpIiUJ1LC%
Insulation
I&rhollc Finail addr0s D Demolition
5,2 Registered lJorne Improvement Coutraclor(HIC)
IIIC Registration Numlier F%piration Date
I IIC Compao) Name or I IIC 1(eSklrant Name
No.and Street Email address
City/Town,State ZIP
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152.1 ISC(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 ..........a No...........0
SECTION 7&:OWNER AUTHORIZATION TO 89 COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,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 Nana(Electronic Signature) Date
SECTION 7b:OWNER'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 in this application is true and accurate to the best of my knowledge and understanding.
Owner's or 'Witc,
,4oTES:
I. An O%vncr x0o obtains a building permit to do his her own work,uran owner who hires an unregistered contractor
(nut registered in the Home Improvement Contractor(HIC) Program).will!Uy have access to the arbitration
program or guaranty tund under.M.G1.c. 142.A. Other important information on the HIC Program can be lbund at
\%%%,% lla,, �;O% •" I Information on the Construction Supervisor License can be found at%\ok til-1,; 111,
2. \%lien substantial work is planned,provide the infuriation below:
rota) flour area I sq. fl I I including garage. finished basement attics,decks or porch)
Groii living area 154 11 1 ilabilable rouill count
\mohcr offirvillaces ... Ntiltilier ol'bedrooms
Number ol hathrounis Nuollivr oflmlfhalhi
I lie ot'liv.11ing i)itcol Number ol'decks, porches
I 1,11clo'cd
I Foi,il Project Square Footage- it a% he sohstinucd for-I'otal Project Cost-
CITY OF SALE.)0I
PUBLIC PROPERTY
DEPART.,IENT
u.outat rn='�S
sows �-30WMMMGMN MW•Suari►VAOAO&SCMetf'e
ML 0'8-715.9s" 978.74&9Na
HOMEOWNER LICLNSE EXE.MMOV
P1ew Met
Date S
Job Location
Home Owner Addren
Hoar Owner Telephone
Pres"Mailial Address
The current exemption of"Homeowner"was extended to include ownar-0eoupied
dwellings of two Units or less and to allow such homeowners to Cupp an individual far
hire who does not possess a license provided that the owner seta as mWWsatt:
DEFQVMON OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to redder on
which then is, or is intended to ben a one or two Iltmily dweWn& attached or detached
structures accessory to such use arsdlor 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 0®ei4 on a form acceptable to the Building
Ofl7cial, that he/she be responsible for all such worst 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 helshe undentands the City of Salem
Building Department minimum inspation procedures and requirements and that hedshe
Mill comply with said procedures and requir entss
HOMEOWNERS SIGNATURE �
APPROVAL OF BUILDING C pwrOR
See other Bids for state code
CITY OF S.1t. Nf, AUS,kcHuSETTS
JLMDLNG DmixnuuNr
I'0 WASHLNGTON Srim, }"FZ001
F,kx(978) 714984d
'UJ(BERLfiY DItLSCOtl
MAYOX Motsw ST.?Ml1s
01RUT0It Of nat1C PRoPEATY/Karte4G COIQIISstONEI
Construction Debris Disposal Affidavit
(required fors demolition and renovation work)
In accordance with the sixth edition orthe State Building Code, 780 CUR section 111.J
Debris, and the provisions of MGL a 40, S 34;
Building Permit a is issued with the condition that the debris resulting from
'his work shall be disposed of in a properly licensed waste disposal raeility as defined by NIGL e
1 11, S I JOA.
The debris will be transported by:
911u+-fl, S�orc .-
(nurna ut'Aaul�r)
The debris will be disposed orin :
(name or fpmlity)
(,ddra, orsml„y)
nrn�mceu(,ermitrpphc�nt
!Jfp