18 OLIVER ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7"edition "
Building Dept
Building Permit Application To-Constru t, Repair, Renovate Or Demolish a
O to or Two-Fm Lily Dwelling
Thi Section tor Official Use Only
Building Permit Number: 4 Date Applied:
Signature:
BuildingCommissioner/ c or B � Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
X 116 061.rerL. ST
I.I 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 ft) Frontage(ft)
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'
2.1 Owner'of Record:
'SA.swEt µ@rScH
Y Name riot) Address for Service:
/\ X28 - 2 tS- S78b
Si azure Telephone
S TION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
Y/ 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': Zrur rLeMoTze� OF ro to o F . 13
AeAaA ,..e�.0(240l46A) / [rur I1K MO,E� of 2.vn puvas. A"
AO,% s..E 6..urS wunn SSOt�rl' �J.«AC.- STaocN�-4� -hNVcmf� 8w m
SC F-La]R
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 1 D Ova 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ -(,coo ❑Standard City/Town Application Fee
X ❑Total Project Cost (Item 6)x multiplier x
3. Plumbing $ -R,Oa 2. Other Fees: $
4. Mechanical (HVAC) $ b crvo List:
5. Mechanical (Fire w
Sup ression) $ NA Total All Fees:$
Check No. Check Amount: Cash Amount:_
6. Total Project Cost: $ Z l poo Paid in Full ❑Outstanding Balance Due: -
Y L
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number. Expiration Date
Name of CSL-Holder List CSL Type(see below)
a
Address T Description
U Unrestricted(up to 35,000 Cu.Ft.) _
R Restricted 1&2 Family Dwelling
Signature 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,§ 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........... ❑
SECTION 7a: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
I, SAME S wkKsc It, ,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
X behalf.
SAAAE.S L. KE''rCcH
Print Name
Sgature wor Authori ent Date
(Signed un 'ns
and nalti ofperjury)
NOTES:
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)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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) t7rl10 Orn+ (including garage,finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) (D Se Habitable room count S
Number of fireplaces Number of bedrooms L
Number of bathrooms 2 Number ofhalf/baths i
Type of heating system Cy AS Number of decks/porches /
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF SALEM
<l r PUBLIC PROPRERTY
DEPARTMENT
. � J
I,�1K l•r.;
I„ \\ vJ llV...•':l:?I I r I I \I, \L\•�\� i. .. I ,.I I
III 'I's.•4;..r•15 • 1 \X ,'s.'a.- 1.14e
Construction Debris Disposal .affidavit
(required li)r all demolition and renovation work)
In accordance \%ith the sixth edition of the State Building Code, 780 CNIR section 1 1 L5
Debris, and the provisions of MGL c 40, S 54;
Building Permit h is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal Incility as defined by MGL c
I 11. S 150A.
The debris will be transported by:
'r6*►
lname of hauler)
I he debris will be disposed of in
T(�v
(name of Iacility)
TO'b
(address d t]cllity)
watt cof p.r ,qt bean(
`I La o9
late
4
•r'
CITY OF S kLEM
PUBLIC PROPERTY
DEPARTMENT
KIOF�av,vw-n L
MAYOR 130WAASUNGTON S-MW•
SLLO(NA>IAOR,'361'IS 01970
TeL 976-70-9S"*FAx.978-740-9"
HOMEOWNER LICENSE EXEMPTION
Please Print
Date -IJ-0,101
Job Location t% o�s veL sr,t eer
Home Owner Address 1b at-rveo- Sro-� AM *-
Home Owner Telephone S za zt s TIS S
Present Mailing Address 18 e-1.44_ sc4mef- ^T-. 2
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or lea 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 them 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 mora
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 requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INS ECT;
See other side for state code