5 ROOSEVELT RD - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
�y Massachusetts State Building Code, 780 CMR, 7ih edition '
Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling 411100M
This Section For Official Use Only
�\ Building Permit Numb r. 4 Date Applied: /,,
Signature: r [Y
Building Commissioner/Inspector o(Buildings Date I
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
S GeuOCeV40- RD-
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 ft) Frontage(tt)
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?
Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
/11E7L. R. FH/2riQ ��ooSE✓4T kr)
Name(Print) Address for Service:
A//22Ae, 47d'-7$1J-ao11
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': iPEiyo✓s BYrS,'XWx .2a..F Slvy�LGe-S Dawn/ za
2942s aivaa. APPLY ;P£fXlIQll Mn AEY1,AY11XWr. 7y/X_A' )RE t ooF WSra'
/V6W itfATa7Z7FLS
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ / 5,06. a 0 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
�• o
5. Mechanical (Fire $
Su ression) Total All Fees:$
Check No._Check Amount: Cash Amount:
6. Total Project Cost: $ /500. 00
❑paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
• • License Number Expiration Date
Name of CSL-Hplder List CSL Type(see below)
T Description
Address
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 I'I
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
1 /I/FJL ,Q, 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.
A//1Fz_
Signature of Owner 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
Si ned 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. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 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 halfibaths
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"
l
CITY OF S.0 .M
PUBLIC PROPERTY
DEPARTMENT
Meas 13ow,muwe MU S718ar•
sMAK MAaMoMr,s 01970
nM.TW745-959S•FAX.978.740-*4
HOMEOWNER LICENSE EXEMPTION
Plea"Friet
Date GLa.:J i6t.z��y
I
Job Location RD
Home Owner Address S R wse6e z e,
Home Owner Telephone 97s-?Y/-o o 1 i
Present Mailing Address -r R.0.5eyeer kh
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.
DEFINMON 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 Earn 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 2F
APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
I': q-.\,I II\i..,,\1r!I:Ir ♦ l.�l
III ♦ I:NX:'i'%-'4=- ,.${i,
Construction Debris Disposal Affidavit
(reLluired lbr all demolition and renovation work)
In accordance %kith the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit ft I is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
�27yslDC CAk�^'�'
(name of hauler)
The debris will be disposed of in
(name of facility) _
(address of facility)
vgnature of prnuit applicant
date