B-19-1235 - 0008 ANADRANT ROAD - Building Permit The Commonwealth of Massachti§VUs�I 'i
Board of Building Regulations and Standards CITY OF
p: Al 0 SALEM
Massachusetts State Building Code, 78
t Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
Thts.: ection Fov fficial Use Or ly
Building•Permit Number: xDate Applied
'Building Offici L,(Pnnt Name) Sib e Date
l ;SECTION 1:SITE INFORMATION
1.1 PrMAddress: h 1.2 Assessors Map&Parcel Numbers
✓ Ma Number Parcel Number
l.la Is this an accepted street. yes no P
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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:
Public Q3� Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2:' PROP.ERTY;OWNERSHIP
_. _
,?_
2.1 w er'of Record:
kw-et... -
Name(Pr t) Ci State,ZIP rb�,J-e a
No.and Street Telephone Mail Address
SECTION3:.1)ESCRIPTION OF PROPOSED WORKZ(check:::'all that apply) ,
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Workz:
Z 40L— ��F
SECTION 4. e di
ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Ufficial'Use Only
Labor and Materials
1.Building $ 1 Buildmg'P-ermit Fee $ Indicate how fee;is.determined
2.Electrical $ ❑Standard CWTown Application Fee
❑Total Project Cost3:(Item 5);x multiplier ' x!
3:Plumbing $ 2 Other Fees.. $
4.Mechanical (1 VAC) $ PE
5.Mechanical (Fire
Suppression)
$ Tota1_All Fees $
Check No Check Amount Cash Amount
6.Total Project Cost: $ ( a ❑xPaid to=Full t❑'Outstanding.Balance Due:''
G;ra��. u� v • �� 1 - S1z -�� �3
SECTL0N 5 :CONSTRUCTION SERVICES }
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Typed Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D 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
City/Town,State,ZIP Telephone
SECTION:6:WORKERS';COMP;ENSATION INSURANCE AFFIDAVIT(M.G.L.,c.152.§ 2$C(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
ON AGENT..O MI R CONTRACTOR APPLIES FOR BUILDING PERT
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 7b. OWNER: OR AUTHORIZED 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� hm,�? 12o 111q11�
Print Owner's or Authorized Agent's Name(Electronic Signature) 6ate
NOTES:
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
www.mass.gov/oca Information on the Construction Supervisor License can be found at w-A,-w.mass.gov/dps
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"
Y
' BUn DNG DEP,kRT\L&NT
120 WASI,€NGTON S7REL7, 31t°FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
Kj`gBFut >~Y DRISCOLL
MAYOR `I l io.%w ST.PmRRE
DimcToR of PuBLic PROPERTY/BUMDLNG co`1LxassiaNFR
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with 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# 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
111, S 150A.
The debris will be transported by:
1�--(name of auler)
The debris will be disposed of in :
(name of facility)
Wa 01A`
(address o"facility)
/I 414h1\-1D
signat= permit applicant
"te -
dcbrisaffdoc
CITY OF SALEA MASSAaR SE ns
BUILDING DEPARTAENT
120 WASIIDv(,"PON STREET,3"0 FWM
TEL(978)745-9595
K OERI.EYDRISOML FAX(978)740-9846
MAYOR THOMAS ST. MPM
DIRECTOR OF PtIBLICPROPERTY/BL11I DING oDA&IISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE:
JOB LOCATION
HOME OWNER ADDRESS: L/
PRESENT MAILING ADDRESS:
The current exemption of"Homeowners"was ex
tended to include owner-occupied dwellings of two(2)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 own 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 access6ry 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 the 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 pr edures and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR