0000 BAKER'S ISLAND #460091 - BP �2gcKlgg
The Commonwealth of Massachusetts Y OF
IT
SALEM
W
Board of Building Regulations and Standards CIT Massachusetts State Building Code,780 CMR wed Mur 2011
1.I) Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
Building Permit NumDea , Dffie od —
'rBaildiog sial(Prtltt e) lrignairna '
�, ` SE�::1'rt?tV 1:t4i772i iBiV1A'i'TO3V
1.1 Propertyefs� .tom, 1.2 Assess`*?p&Parcel Number r
1.1 a is this an accepted
str .cr. yes_ no Map Number Parcei Number/
13 Zoning Information: 1�Property Dions:
rr -79
Zoning District Proposed Use Lot Area(sq 1t) Frontage(5)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public D Private z.Me., _ Outside Flood Zone? Municipal D On site disposal system D
Check ifmo
SECTION2 PROPERTYOWN
2.1 � �erriofRecorJJ 0.a.,
J. a .,
d: ffi,G,rlrn97�n ll1J� to/&'87
Name(Print) City,State,ZIP
13c;1 ;0;Ck0is ST 97g•qVf-i'mr �P° A Z L',g still
No.and Street Telephone Email Address Z
SECTION&DESCRIPTION;OF PROPO$ED WOMO(check all that apply)
New Construction D Existing BuildinP Owner-Occupied Repairs(sX I Alteration(s) D Addition D
Demolition D Accessory Bldg.D 1 Number of Units Other D Specify:
Brief DescriptioaffProPgsed Wor12:
L4ce- u
4
SECTION 4:ESTMATED CONSTRUCTION COSTS
item Estimated Costs: 00eiai Use Only
(Labor and Materials
1.Building 1. Suildirg Permit Feet$ Indicate how fee is determined
2.Electrical $ O Standard Cityfrown Application Fee
E3 Total Project Costs(item 6)x multiplier x
3.Plumbing $ 2. Other Fees:
4.Mechanical (HVAC) $
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount: .
6.Total Project Cost: $ ❑Paid in Fflill d"#anft Balance I:?ge: ..
Mc""kL'Gro t) /2.t°
&1,,CTION5 COi�TRVC'ITt011Sli;I3VICES
5.1 Construction Supervisor License(CSL)
License Number Expiratian Date i
Name of CSL Holder )
List CSL Type(see below)
No.and Street TYPe Daaadpfino .
.. U I Unt=Weted:... din u to 35 Olio cu.fL
City/Town,Stale,ZIP Restricted 1&2 F Dwelling
M I MOSOMY
RCRoo Coverm
W5 Window and Si "
l SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
H
HIC Company Name or HIC Registrant Name IC Registration Number Expiration Date
No.and Street Email address
Ci /Town State ZIP Tel hone
SEMON 6,WOREERS"COMPEN5AUON 94SURANCE AP'P'777"T OLQ 1G c.152.4?I5C%)
Workers Compensation Insurance affidavit must be,completed and submitted with this application. Faihue to provide
this affidavit will result in the denial of the Issuance of the building permit_
Signed Affidavit Attached? Yes ..........O No...........❑
SE Tat(lWitlERiIIPfHbR12A xbBE CbI.E3TA W�IEIv .
OWR'3 A T �'OIt 13., IIaKd PER1►fIT
T,as Owner of the subject property,hereby authorize—
to
uthorize.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 71a-OWNER'(Rt 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 he best of my knowledge and understanding.
Pent Owner's or F.uthorized Agent's N e ctronic Signature) - Date �
NOTL?Sx i Y
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(HIC)Programs),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
imLmmX2y,'oca Information on the Construction Supervisor License can be found at www.mass.eov/das
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.It) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of haWbaths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
T3. "Total Project Square Footage"maybe substituted far"Total Project Cost"
QTY OF SALEM, MASSACHUSETTS
is BUILDRm DEPARTMENT`
r 120 WAsFaNGTONSTTTEET,JlmFlOOR
TEL (978)745-9595
KIA BERL.EY DRISOML FAX(978)740-9846
tAYOR THOMAS ST.PTERRE
DIRECTOR OF PLTBLICPROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT.
Date �E /r7—`K
Job Location y4 ��Of 14
Home Owner Address �_ 3 PIC AI C4012S f%7� /j L1Y1jZt tfOYr,�j�j� �j�8 7
Present Mailing Address �� C
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
OWCFSAS WSSACHESETP
BUUMDtare rr
> 124 W/ASf�7CTrS711tBBT,31°
71st.O78 745-9M
FAX 740-9M
SDN6ERIEYDIR>sG�3.
MAl'QR 7NMUSST2AM
Dcxrt�ucls�,�aG
Construction Debris Disposal Affidavit
(required forall demolition and,.renovation workj
in accordance with the sbrth edition of the State Building Code, 780 CARR, Secdon 111.5 Debris,
and the provisions of MGL c40,S 54; Building Permit A is Issued with the
condition that the debris resukkv from this wort shah be disposed of in a property lik eased
waste deposit facility as dethred by MGL c 111,S 156A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name ffof facility)
�at�d� 11� d196�
j (address of cility)
Signature of applicant
Date
k,
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