2 RIVERBANK RD - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards "� `� ' +M
SALEM
Massachusetts State Building Code,780 CMR
v" 1
11�il��i, U
Building Permit Application To Construct,Repair,Renovate Or De>>SiiHst�i��
One-or 71vo-Family Dwelling
This Sot o For i> oral U44 .
Building Petmlt,Nut tE- Date Applied:
1 $
`� B ir7ding 018ciet(f+vd e) Signabre Data
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SECTIONli SITE 19�iFOBMi1TION
1.1 Property Addr 1.2 Assessors Map&Parcel Numbers
6 1.1 a Is this an accepted street?yes_ no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoi—. Dwftxt Proposed Use L.ot Area(sq R) Frontage(R)
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:
Zone: _ Outside Flood Zone? el stem ❑
Municipal❑ On site disposal system Public❑ Private❑ Check if yes❑ _
SECTION 2c P1tOPER7 P OWN`ER&HII't
2.1 OwnerrofRgcora: (r QuhTr^^.. SjeA /'y1/�' 0) �7y .
�yq� Qux Nr�o
Name t) City,State,
ZIP
d / (P 17 - WI-.�317
No.and Street Telephone Email A s
SECTION 3:DESCRIPTION OF PROPOSED WOItKr(eheck aff that apply)
New Construction❑ Existing Building Cl Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition O
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Dtscri on of7ro sed Werk'
3heA reMOrAI new ShOel D- rpt 11QW LOC,4,75:;; -K Pe .s'I� r .
SECTION 4:ESTA'IATFII COPtSTRUCT1nN COSTS
NE:dm1atedT. Official Use OIIIItem 1.Building uilding Permit Fee..$ indicate how ee isdetermined:
tandard City/Town Application Fee
2.Electrical otal Project Cost'(Hem 6)x multiplierx
3.Plumbing Other Fear:4.Mechanical (HVAC) $ t:
5.Mechanical (Fire $ Tota:All Fees:$
Su ression
vl Check No. Cheek Amounk Cash Amount; .
6.Total Project Cost: $ 3 Z W 13 Paid in Full ❑Outstan ' Balance Due:
SIL mPi� t_—P l> •C .
SE LEON 5: CONS7'R11C' ION Si MVI
5.1^Construction Supervisor License(CSL)
License NumberExpiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street
U I Unrestricted(Buildings to 35,000 cu.ft.
R I Restricted 1,@2 F Dwe '
City/Town,State,ZIP M Absomy
RC Roofing Coverin
WS Window and Siding
SF Solid Fuel Burning Appliances
I I insulation
Telephone Email address D I 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 Tel hone
SECT70N 4:WORKERS'COMP1CMATI4DN MURMCE AFFIDAVIT OLG.L,c.152.3 25C(0)
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...........O
SkCTtON 7a OWNER AUTHORIZATION TO Itis C6MIP1ETED WIUN
R'S AGE1!TT C0 CT91t. FOR -mMOW—
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.
Print Owner's Name(Electronic Signature) Date
SECTION 76:OWNEW OR AUTHORIZES 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.
F✓Gw Bvxlw,
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
Sp
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
wunv.mass.sovIoea Information on the Construction Supervisor License can be found at www.ntass.eov/dos
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 Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
r
QTY OF SALEM, MASSAC HUSE TTS
i BUILDING DEPARTMENT'
\ m 120 WASHINGT0NSTREET,3" FLO0R
TEL.(978)745-9595
KIA BERLEYDRISCOLL FAX(978)740.9846
MAYOR THOMAS ST.PIERRE
DIRECTOR OF PUBLIC Pitom-r Y/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT.
Date 6 0 ' O IL
Job Location //{ 56lg m Mk 0 (y 70
Home Owner Address S6fM AS Gi`JO✓Y
Present Mailing Address 54me !S u90oy_
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.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTO
All
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