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1 MCKINLEY RD - BUILDING INSPECTION 1 The Commonwealth of Massachusetts Town of Board of Building Regulations and Standards a� Massachusetts State Building Code, 780 CMR. 7'"edition 40"Wng Dept Building Permit Application To Construct. Repair, Renovate Or Demolish a llilam- One-or Two- 7 Dwelling PThis or Offcial UseOnly Building Permit Numbe . Da Applied:Signature: Building Co issioner/ ns Date SECTION 1:SITE INFORMATION 1.1 Property Addresa: p� 1.2 Assessors Map& Parcel Numbers {'LlGI'�!r'f C LY I.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 it) Frontage(R) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Public 13 Private❑ Check if es❑ SECTION 2: PROPERTY OWNERSHIP' 2MNari 1 Owner'of Record: Address for Service: ignature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction❑ Existing Building Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ I Other ❑ Specify: Brief Description of Proposed Work=: ognt C 1)-L C ti SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item Labor and Materials I. Building S (PP. p(J I. Building Permit Fee: S Indicate how lee is determined: '. ❑Standard City/ own Application Fee 2. Electrical S ❑Total Project t'(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S -- 4. Mechanical (HVAC) S List: 5. Mechanical (Fire S Total All Fees: S Suppression) Check No. _Check Amount: Cash Amount: 6. Total Project Cost: S/,,7_0 mr &90 0 Paid in Full 0 Outstanding Balance Due: SECTIONS: CONSTRUCTION SERVICES r 5.1 Licensed Construction Supervisor(CSL) License Number Expiration Date Name of CSL Hplder List CSL Type(see below) Address T Description U Unrestricted(up to 35,000 Cu. Ft.) Signature R Restricted 1&2 Family Dwelling M Masonry Only RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Company Name or HIC Registrant Name Registration Number Address Expiration Date Signature Telephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 2SC(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 .......... ❑ No........... ❑ SECTION 7s: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, 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. Signature of Owner Date SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behal rliving ameG--AC) ure of Owner or Authorized Agent Date d under the ains and enalties of r'uNOTES: n Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor ot registered in the Home Improvement Contractor(HIC)Program),will nor have access to the arbitration ogram or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and nstruction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I0.R6 and 1I0.R5, respectively. hen substantial work is planned,provide the information below: oors area(Sq. FL) (including garage, finished basement/attics,decks or porch) iving area(Sq. Ft.) Habitable room count r of fireplaces Number of bedrooms r of bathrooms Number of half/baths f heating system Number of decks/porches f cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" ~' .y CITY OF SALEM _j � PUBLIC PROPRERTY '�...\• DEPAIt'I'LIENT .., ':lldl Construction Debris Disposal Affidavit (rcquiied lbr all demolition and renovation work) In accordance \v fill the sixth edition of the State Building Code, 780 C•NlR section 1 1 1 S Dcbris, and the provisions of MGL c 40, S 54; Building Permit N is issued with the condition that the debris resulting front this work shall be disposed of in it properly licensed waste disposal facility as defined by MGL c I11. S 150A. The debris will be hansported by: tname of hauler) I he debris will be disposed of in (name of facility) laddre„ of lacJirol apualw[ �>f p:nmt .y\pllcant dale • li CITY OF SALEM PUBLIC PROPERTY DEPARTMENT NAVM I3eW 9W*G7o„S1'RM9SumN.NUAOLL.-56MOr970 lki 972-745-95"• FAx.978•740.984 HOMEOWNER LICENSE EXEIMMON Please Print Date (;• ( ` 0 ,j Job Location Home Owner Address Home Owner Telephone — I'Z-o!o Present Mailing Address 5A- _ 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 who 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 dwellin& attached or detached smwtures 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 understands the City of Salem Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and r uiremen . HOMEOWNERS SIGNATURE APPROVAL OF BUILDING INSPECTOR See other side for state code CITY OF S.II.E.x1, N xSSACHi;SETTS BL'ILDLNIG DEPARTMEINT 130 WASHINGTON STREET, 3'a FLOOR TEL 97 745-9595 FAx(9711) 740-9846 KINiBERI.EY DRISCOLL MAYOR THobus ST.PIEm DIRECTOR OF PUBLIC PROPERTY/BUIIDLVG COSMSSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Annlicant Information Please Print Legibly Na1T1e (Busintat Organizatiamindividu J): Address: 1plC /�/G!4- !'a _ City/State/Zip: S'/�l Phone M: ��7 102© { Are you an employer?Cheek the appropriate box: Type of project(required): I.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet : 7• ❑Remodeling ship and have no employees These sub-contractors have 11. ❑ Demolition working for me in any capacity. workers'comp.insurance. 9. E] Building addition [No worker9 comp. insurance S. ❑ We are a corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their 3. 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. c. 152, ¢1(4),and we have no 12.*oof repairs insurance required.)t employees. [No workers' 13.[]Other comp. insurance required.) •Any applicant ttud chtxiu ba#1 most also fill out the section below showing their wmkm'compenwiwn policy.informalion. '1 who submit this affidavit indicating they ane doing all work ad then hire outside eon[m ors must suhmit a new aftldavit indicting such �f'ontrmnon that check this box most attached an additional sheet showing the name of the sub-contractors and their workm'rnmp.policy infomuuon. I am an employer that is providing workers'competrsadon insarance far my employees. Below Is she policy and fab s!q information. Insurance Company Name: Policy #or Sclf-ins. Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration tate)_ Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a rine up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. 13e advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer ' of d e # yin and pen hies of perJury that the information provided above is true and carreea cion t ¢ ��� Date: Phone#: 4P����7 Official use only. Do not write in this area, to be completed by city or town affi,.&I City or gown: Permit/f.lccme# Issuing Authority(circle one): L Board of Ilealth 2. Building Department 3.City/town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: __ _ ___- ._ Phone#: