4 AMANDA WAY - BPA-16-351 FINISH BASEMENT- r . 'RECEt
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'rhe Commonwealth of Massachusetts S VIC fY OF
� Board of Building Regulations and StandarjF' SALEM
4it Massachusetts State Building Code, 780 CMN 'APR f 3 A �?,4s Sfar loll
Building Permit Application To Construct, Repair, Renovate Or Demolish a
M One-or Tivo-Family Divelling
This Section For01`06ul Use Onl
19 BuilJingPermitNumber: Date Applied:
"Building Otlicial(Print Name). Signature ' Date
SECTION li SITE INFORMATION..'
1.1 Proper Address: 1.2 Assessors Mnp g Parcel Number
AMqu`�a Vj TALEM MA oiajo
Rj�
his an accepted street?yes no Map Number Parcel Number
ing Information: 1.4 Property Dimensions:
istrict '- .Proposed Use - Lot Area(sg R) Frontage(II)JingSetbacks(R) .-. .. . - - Rear YardFront Yard SiteVoidsn:J �Providnt Beguiled Provided Bcquited Provided
r Supply:(M.G.I,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Private(3 Zane: _ Outside Flood Zone? Municipal 1p On site disposal system ❑Check if es❑ .SI ION2:, PROPERTYOWNERSHIP!e i of Record: f BEM M� d�Q Q
Rdo€R jI ass 7
me Print _ City,State,ZIP
�{ i9mnana w i q e_j -one Rola�auu>�R� yAIkO.GvA(
No.and Stroet Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK;(check all that apply)
New Construction❑ Existing Building❑ 'Owner-Occupied R Repairs(s) ❑ Altemtion(s) O Addition ❑
Demolition ❑ I Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work=: P UTHI" MT jLfs�Gf '
oa�la�wU.-� c�luu �IufJb � r-I.au�,r
SECTION 4:ESTIMATED CONSTRUCTION COSTS
hem Estimated Costs: Official Use Only
Labor and Materials
I. Building $ QtUO -�lN7U ' I. Building Permit Fee:S Indicate how fee is determined:
❑Standard Cityrrown Application Fee
1. Electrical S 'goo ❑Total Project Cost?(Item 6)s multiplier s
1. Plumbing S 2!1 Qiher Fees: S /
a.Mechanical (HVAC) S List: � �•�
5.NlechanicaI (Fire $ Total All Fees:S-
suppression)
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S 0000 (MA,4) ❑Paid in Full ❑Outstanding Balance Due:
hv-)'t t_r'--o %{ It `�
g
% .;t,'r1.'11 1 SECTION5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
is ::; r• ` '' License Number Expiration Dale
Name of CSL Holder List CSL'rype(see below)
Type - : - Description .
No.and Street -
U Unrestricted B ildings tip to 35,000 cu. Il.
R Restricted 1&2 Family Dwelling
Cityfrmm,State,ZIP M Masonry
RC Roo Covcrin
WS \VindowandSidin
SF Solid Fuel Burning Appliances
1 I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Nome or HIC Registrant Name
No.and Street Email address
City/Town, State ZIP Teie hone
SECTION 6:WORKERS'COMPENSATION 1.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 Witance of the building permit.
Signed Affidavit Attached? Yes ..........O No...........❑
SECTION 70:OWNER AUTHORIZATION TO BE COMPLETED.)VHEN'
OWNER'S AGENT OR CONTRACTR APPLIES FOR BUILDING PERMIT'
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
R�O�(!rY k 19 if�tb
o+41i311G
Print Owner's Nanne(Electronic Signature) - Date
SECTION 71b:OWNERI OR AUTHORIZED AGENT DECLARATION
By entering my name below,)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.
Print Owner's or r\uthorized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
_Anot registered in the Home Improvement Contractor(HIC) Program),will nut have access to the arbitration
program or guaranty fund under IsI.G.L.c. 142A.Other important inform ition on the HIC Pfogram can be folt�nl aT --
www max,cov;'oca Information on the Construction Supervisor License can be found at www.mas�
2. When substantial work is planned,provide the information below:
"rota) floor area(sq. ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. ttJ Habitable room coma
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
'rypeorcoolingsystem Enclosed Open _
i. "roml Project Square Footage"may be substituted 1'or"'rutal Project Cost"
C[TY OF SALEM, MASSACHUSE M -
3 . BUILDING DEPARTwNr
120 WASHNGTON STREET,3ft0FLOOR
TEL. (978)745-9595
FAX(978)740-9846
KIMBERLEY DRISCOLL
MAYOR Tr-IOMA.S ST.PIERRE
DIRECTOR OF PLMLICPROPERTY/BUILDING CONINflSSIONER
HOMEOWNER-LICENSE EXEMPTION
PLEASE PRINT.,
Date 04-13-Ib `
Job Location `� bM4 011 WIN SA Vlk YYIA 01g10
Home Owner Address 4 AMAIJOA Why SAIFVYI ►�A O1410
Present Mailing Address 01g1t7
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 IA�AAAIIL
APPROVAL OF BUILDING INSPECTOR