46 RAYMOND RD - BUILDING INSPECTION 5
s
a rhe Commonwealth of Massachusetts
} Board of Building Regulations and Standards CITY
1, Massachusetts State Building Code, 780 CNIR, 7" edition OF SALEM
RevisedJanuary
Building Permit Application To Construct, Repair, Renovate Or Demolish a
�{I Otte-or Tiro-Fumily Dwelling
A[ VJl This Section For Official Use Only
Building Permit Numbe . Date Applied:
Signature: /Li u Ldl7��L)
Building Commissioner/ nspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property-Address: 1.2 Assessors Map& Parcel Numbers
�\ L-1& o )q* 0 -, d 2d
I.la Is t�pted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq Il) Frontage(Il)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Require) Provide) 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?Public❑ Private ElZone:
if yes❑ Municipal❑ Onsite disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1nert of Record,_
f7 id 1-/!Cfj., Yep
Name Print) Address for Seryce:
A 97P
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ 1 Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work': Q X `J' On 9 e She&
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
I. Building $ 1. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S C3 Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S e--
4.
`-
4. Mechanical (IIVAC) S List: c,
5. Mechanical (Fire S
Suppression Total All Fees:S
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: SO� �`j Q/ 0 Paid in Full 0 Outstanding Balance Due:
r
1 II
SECTION 5: CONSTRUCTION SERVICES +
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL-I[older
List CSL-Type(see below)
Tc Descri tion
:\ddress IJ Unrestricted(up to 35,000 Cu. Ft.)
R Restricted I&2 Family Dwelling
Signature M I %lasonry Only
RC Residential Roofing C'o%crin
Felephone WS Residential Window and Siding
SF Residential Solid Fuel Bunting Appliance Installation
U Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
FITC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature 'relephone
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
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.
Signature of Owner Date
`L SECTION 7b:OWNER'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
behalf.
Print Name
a f� /a- — Co
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties 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. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.145, 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.) Ilabitable 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 he substituted for"Total Project Cost"
• CITY OF S.XL.EM
PUBLIC PROPERTY
DEPARTOMENT
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wrae 130WmM11Grq MMMT•U+art VAMAC)&S1rM011'0
ML 9-6-745.9s"•K..s 9?8.74&964
HOMEOWNER LICLNSE EXEMPTION
Plow Print
Day
Job Laeadois y/O a d k2 d
Home Owner Address C
Home Owner?elepbone v v Z
Presw Mailing Address //&
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Unita or fess and to allow such homeowners to engage an individual for
hire who.does not possess a lieenso provided that the owner acts as supervisor.
DFj1NM0N OF HOMMWNEIt
Person(a)who owns a parcel of food on which hWsM resides or intends to resides,on
which there is, or is intended to be.a one or two &mily 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements,
HOMEOWNERS SIGNAMM o /
APPROVAL OF BUILDING DiSPECTOR (, o,
Sea other side for state code