13 RIVER ST - BUILDING INSPECTION (2) MONSOON
��
V � The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
40"00-
Massachusetts State Building Code, 780 CMR, T"edition Budding Dept
Building Permit Application To Construct. Repair, Renovate Or Demolish a
One- or Tito-Family Duelling
This Section For Official Use Only
Building Permit Num Dale Applied: 3 3/ Zoe
Signature: — 1
BuilJmotissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
1.1 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.O.L C.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public Private 13Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
C>a(i�Aa LL.0 13 !Z iV e r S r
ame(Print) Address for Service:
ycr,�A LL[I b�-5"9�-4217
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ - Owner-Occupied ❑ 1 Repairs(s) tion(s)_JWI Addition ❑
Demolition Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':Ta,ee 0,1T O 10 KrHq ji -T9AfT44L ,OeW
F{.ATfrAaM Gr/t� Jy�IJ4a4__�_�LF `�5' Qvl7s-�M
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building S zoo •Ob 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S S7-000.00 ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing E � 060,0 2. Other Fees: E
4. Mechanical (HVAC) 5 List:
5. Mechanical (Fire S Total All Fees: S
Su ression
Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: S ?Or 00.01 0 Paid in Full 0 Outstanding Balance Due:
- 1
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
' '•
License Number Expiration Date
N;)me of CSL-HyWer List CSL Type(sec below)
Address T- Descri non
U Unrestricted u to 35.000 Cu. Ft.)
Signature R Restricted I&2 Famd Dwellin
M Mason Only
RC Residential Roofin Coverin
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 Numqtoprovide
Address
Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c
Workers Compensation Insurance affidavit must be completed and submitted with this applicatio
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, JLI,C as Owner of the subject property hereby
authorize to act on my behalf,in all matters
re live to work aul riized by this building permit application.
O tA- tt� t2o�l?a„ lcc. 2/3i�2c�o�
ire of Own Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, 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
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of per u
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 I I O.R6 and I IO.RS, 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 Cost"
CITY OF S.UY.\i
PUBLIC PROPERTY
DEPARTMENT
K1�0�!w�y".•n
NAV'Oa 130 WMN"GTnM S71GaT•SMLM#.,.MAUApl{31rrR 01970
TV&TW7154S"•FAL 97L740.96"
HOMEOWNER LICENSE EXE.M MON
PleassPrint
Data S 3) 206 p'
Job Location / 3 Uc IL1eYL tr-e ,7"
Home Owner Address / 3 RN-cit S T'r c c-r
Home Owns Telephoneo —
Present Mallin`Address / � Iver Sr r a 'T-
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 panel 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 wont 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 Td
7,ulremen:,
HOMEOWNERS SIGNATURE e���n .�cc
APPROVAL OF 13UILDING INSPECTOR
See other side for state code
I
CITY OF SALEM
PUBLIC PROPRERTY
DEPAR"I'MENT
I': AAll IV)H)lr • `,.0 111. M.,.;V !. ., � .•. '1
I 1 1 V'S '43-93;); • I \s ,7x '4:9841
Construction Debris Disposal Affidavit
(rriluired liir all demolition and renovation work)
In accordance with the sixth edition offhe State Building Code, 780 CMR section 111.5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit N is issued with the condition that the debris resulting from
this work shall be 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
(name of facility)
address o1'Iacilirv)
L LC,
NLnalnre Ul perllllt allpllcant
ilatc