13 KOSCIUSKO ST - BUILDING INSPECTION 7c� ck 16
The Commonwealth of Massachusetts D ITY OF
Board of Building Regulations and Standards ` Wx � ' =
D Massachusetts State Building Code,780 CMR Revised Mar 2`011
i Building Permit Application To Construct,Repair,Renovate Or DNWlW2 'P 3: O q
One-or 7tivo-Family Dwelling
bniyBuilding Para+(,Nitmr I DaVAVplied:
Imo" OfAetal(Pntrtldame�" 8isfirte
{ �E,CTIOIV 1:$I'i'R�Ip'ORlkt4'1Tf1N
r 1.1,_P,r,op�erty Address: 1.2 Assessors Map&Parcel Numbers
X13 tG+S Ll 5iz.. 5G
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq T) Frontage(II)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public[3 Private❑ Checkifyes❑ . .
SECTION 2: PROPSRII'qct NBRSH_LPt
1 Ownert of Record:
0
Name(Print) City,State,ZIP
l3 iGvSGwSlr Sr x$,1 -591-,169i b01(, (;,
No.and Street Telephone Email Address
SECTION&DESCRIPTION OF PROPOSED WORK=(olteck all that appl3')
New Construction❑ Existing Building O Owner-Occupied 13Repairs(s) ❑ Alteration(s) ❑ Addition 0
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work :
QtiPV/bG Ort-^'`osr /�'t�t- GL�3o/�AI.pS w +'rbl' {}/alG.4li �L/kN�< �o/�dZ�)
SECTION 4:ESTPJATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials &
1.Building $ 1. Building Permit Pea:$ Indicate how fee is determined;
0 Standard City/Town Application Fee
2.Electrical $ p Total Project Cose(Item 6)x multiplier .x
3.Plumbing $ 2: OtherFeos: $
4.Mechanical (HVAC) $ :
5.Mechanical (Fire $ Total All Fees:$
1
S14,cession
/\rChe ck No. -Check Amount: Cash Amount-.
136.Total Project Cost: $ Paidin Fall p Outstanding Balance Due:
Mp�lLt,�n q 121 1 U.,
SEGTIOIV5: CONSIAUGTIONSR�rICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder '
.. 4. .- .•. List CSL Type(see below)
No.and Street - 1 1
011
U I Unrestricted(Buildings to 35,000 Co.ft.
R I Restricted l&2 Family Dwelling
E1ty7/Town,
w -
City/fown,State,ZIP I M I Masonry
RC Roofing Coverin
wS SEE
and S*
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(BIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
Ci /Town State ZIP Telephone
SECTION q;WOIiI�R�°CO1t7gEPI6ATION H S[SRAItiCEAFFIDAVIT(NLG.L x.152.3 2")
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 ..........0 No...........0
ACTION 7a OWNER AUTHORIZAtION TO ftg Co WWLETED WIIEIN
0 WN R'S AGENT 4R O ._ CI' R .F(}R . .3NG .__ _
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.
bar, SP,R4NO /
Print Owner's Name(Electr6nic Signature Date
SECTION 9b:OWNEW 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.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
1. 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)Program),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
www.mass.sovloca Information on the Construction Supervisor License can be found at ww'MA1aas.sov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basemenVattics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halFbaths
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'
a QTY OF SALEM, MASSACHUSE M
BUILDING DEPARTMENT
120 WASHINGTON STREET,3"0 FLOOR
'ISL. (978)745-9595
KIMBERLEYDRISODLL FAX(978)740-9846
MAYOR THoms STTIERRE
DIRECTOR OF PUBL[CPROPERTy/BUILDING OC)hWSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Job Location l 3 fG cc6 k_. $G- 6 1 Ct
Home Owner Address 3 0.57c,�5 i,- g ry�t<.� S�c� � � c) 1 q �
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
07 YCFSAL EK MASSAMBETT
BULVMZWettaa;wr
IMWA9DUJ vSrnBer,rROCJt
11aL7�5-9995.
PAX 7149M
BIl�BRiEYDn<S�ffi,L
MAY�IIt ZWUASST.lUM
Dn18crcitcx+rteuc latmaccamomaN n
Construction Debris Disposa/AffrdV&f t
(required forall. demolition and,.renovation work)
in accordance with the skm edition of the State Building Code, M CMR, Seddon 111.5 Debris,
and the provisions of MGL M,S 54; Building Permit# is issued with the
conddtdat that the debris resulting from this work shag be dkposed of in a properly ikensed
waste deposit facility as defined by MGL c 111,S 156A.
The debris
will betransported by.-
Li
y:u I"
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Sign re of app scant
�f z bb 6
Date