25 RAWLINS ST - BUILDING INSPECTION The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
e� Massachusetts State Building Code, 780 CMR, 71"edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Avo-Fomilv Dwelling
(Y1 This Section For Official Use Only
jv"�J Date Applied: OO
y Building Permit Nu ber,
Signature:
Buildii 'o mtssioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
I 1 Property Address: 1.2 Assessors Map& Parcel Numbers
Ma Number Parcel Number
1.I a Is this an accepted street'?yes_ no P
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq fl) Frontage(fl)
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) 1.1 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system 13Public❑ Private❑ Check if ycsO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Own r'of Recor G ��
2�- &G} Cr)Z-!/lf-5 `1
Name(Frio) Address for Service:
,' G4SEL-TI
T75 l ql 33 99
S n e Telephone
ON3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) IV, Alteration(s) ❑ Addition ❑
Demolition Accessory Bldg. ❑ Number of Units j Other ❑ Specify:
Brief Description of Proposed Work':
/ n acf ��I rl Ra, nom
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
1. Building5 2 s,S Q(� 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing 5 2. Other Fees: 5
4. Mechanical (HVAC) S List:
�- 5. Mechanical (Fire S Total All Fees: E
Su ression
Check No. _Check Amount: Cash Amount:
"c' / 6. Total Project Cost: S -&S-OV 0 Paid in Full 0 Outstanding Balance Due:
SECTION S: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
N:)mc of CSL Holder List CSL Type(ser below)
Address T Description
U Unrestricted u to 35,000 Cu. Ft.)
Signature R Restricted I&2 FamilyDwelling
M Mason Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Bumin Appliance Installation
D I 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 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 .......... O No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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.
Si nature of Owner Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
1, V fLF-�A-� I w , ('� ..,AI(q C `J ,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
behalf.
JFF2
Pri N 7�d
Si to a of O ner or Auth rized Agent Date
i ned under the pains and nalties 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
Pro
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 I I0.R6 and 110.115,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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 Open
3. "Total Project Square Footage"may be substituted for"Total Project Cosi'
1
CITY OF SMEM
PUBLIC PROPERTY
DEPARTMENT
KJWWU rrvwvvL
SALeK MA4Adil:56TIS 01970
TEL VS.745-9S93• F.at:976740.984
HOMEOWNER LICENSE EXEMPTION
Please Print
Date S r ° Z02
Job Location ?-T kALO c-I A/S Sl 5,4 Lr A t4 A-
Home Owner Address 2.S 1Z ra&/ S (� A LZ t i M
Home Owner Telephone '7'46
Present Mailing Address Z F kAW c-INS S i. ,gt.TP( i� P �f
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
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 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 '^0
APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SALEM
s `.. PUBLIC PROPRERTY
•�,,.,.� DEPARTMENT
Construction Debris Disposal Affidavit
(tvyoired l'or all demolition and renovation work)
In accordance \\illi the sixth edition of the State Building Code, 7S0 CMR section 1 1 1.5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit N is issued with life condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I 11. S 150A.
The debris will be transported by:
(name of hauler) _
I he debris will be disposed of in :
T S 1'P IL 6—A /277—my 6T)
(nae ul lacility)
Inddress of lanlavl JJJ
a• atute of pent applicant
O
,late