32-34 MOFFAT RD - BUILDING INSPECTION The Commonwealth of Massachusetts
a Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
d Revised Mar 2011
rJ Building Permit Application To Construct, Repair,Renovate Or Demolish
One- or Two-Family Dwelling
[J This Section For Off4cial Use Only '✓` n
Building Permit Number: 94ie Applied:
I Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION i
1.1 Pro erty Addr ss: 1.2 Assessors Map&Parcel Nurnt wrs rn
1.1a 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 ft) Frontage(ft) s
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2. wner'of Record: nn
ICP,10. _t4no\r1S SOIem (nR 010n o
Name(Print) ICity,State,ZIP
`i��d• 919-430-2113
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ 1 Existing Building❑ Owner-Occupied l� Repairs(s) 9- Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Z Other ❑ Specify:
Brief Description of Proposed Work': New +6,en Co' .v-k CLV\d rQ>r1t-liv
Ct�,�rYFer �05�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 157,000,00 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2.Electrical $ oDl)'fT ❑Total Project Cost' (Item 6)x multiplier x
3.Plumbing $ uyw•b O 2. Other Fees: $ x n
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire $ — Total All Fees:
6.Total Project Cost: $ 1il I�
Su ression
Check No. Check Amount: Cash Amount:
❑ Paid in Full ❑Outstanding Balance Due:
1hFlt1 � c7 TO V-l.O . \\�Z.3
L.
All
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
Lis[CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
Ci /Town,State ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152.§ 25C(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........... 0
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
],as Owner of the subject property,hereby authorize A(3enw DOO-K-05 0.
to act on my behalf,in all matters relative to work authorized by this building permit application.
�essice, R-e-vooUs �i tam (1 l.M 11-li-IS
Print Owner's Name(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.
Sessic_tz iZelnot& - r�,2tt/ / (1-{1-I5-7
Print Owner's or Authorized Agent's Nam (Electronic Signamney Date
NOTES:
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.eov/oca Information on the Construction Supervisor License can be found at Lvw .mass.gov/dms
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.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed on
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
aQTY OF SALEM, MMSACME TTS
BUILDING DEPARTMENC
120 WASHINGTON STREET,3"D FLOOR
TEL. (978)745-9595
FAX(978)740-9846
KIMBERLEY DRISCOLL
MAYOR TiOMAS STTIERRE
DIRECTOROFPUBLICPROPERTY/BLu DING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date 11- k�'A
Job Location 37-3q fl-Al t\d
Home Owner Address 3 LA MoT I,--A
Present Mailing Address IA 1 AcYJ Rl ,
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. J
HOMEOWNER'S SIGNATURE VI�1/1 Lia I L_t9^�i .S�
V
APPROVAL OF BUILDING INSPECTOR
07Y OF SALEA AWSAGiL SEM
Bun.DDYGDEPAR mEw
120 WAffmYG7cNSmtEET,3m om
IkL(978)745.9595.
PAX(978)740.9846
x�FRi-FYDRISQ77I.
MAYOR 7}ICK4S STYE=
DmEcTOR or PuaucrRomm1BlmnmrG Q3&moNEn
Construction Debris Disposa/Affidavit
(required for all demolition and,renovation work)
in accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL 00, S 54; Building Permit# is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by.
pauir;( S(al`i (nm
(name of hauler)
The debris will be disposed of in:
r
TraskmaS{eiS Den•aj;+;on I
(name of facility)
(address of facility)
Signature of applicant
ii Li :,z vis'
Date