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0 BAKERS IS - BUILDING INSPECTION t t, I rhe Commonwealth of Massachusetts ''Will Board of Building Regulations and Standards CITY OFSALEM Massachusetts State Building Code, 780 CMR, 7a'edition r Revised lmurrvv Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. ?FRAY i One-or Two-Family Dwelling This Section For Official Use Onl Building Permit Number• Date Applied: Signature: 4kJAK�:--= Buildin ommissioner/Inspector of Buildings Note SECTION 1:SITE INFORMATION 1.1 Prop e Address: 1.2 Assessors Map& Parcel No ben � r � S 1S. /C?,I) - 37 1 -OaZ Al 1.1 a Is this an accepted street?yes nom Map Number Pamc Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Aria(sq It) Frontage(R) 1.5 Building Setbacks(B) Front Yard Side Yards Rear Yard Required Provided Required Provided Required 4system 1.6 Water Supply:(M.G c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal Sy Zone: _ Outside Flood Zone? Public❑ Private Check if es❑ Municipal❑ On site dispo SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record' Nume(Print) dssforService: 9L Signature Telephone SECTION 3: DESCRIPTI N OF PROPOSED RKs(check that apply) New Construction❑ Existing Building Owner-Occupied Repairs(s) Ee I Alterations) ❑ Addition 01Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other ❑ Specify: Brief Description of Proposed Work: A/A--1.r/ R0I7J!!�: SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Ofllelal Use Only Labor and Materials 1. Building S 1 1. Building Permit Fee: S Indicate how fee is determined: ❑Standard City/Town Application Fee ?. Electrical Is ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S 4. Mechanical (IIVAC) S List: 5. Mechanical (Fire S Suppression) TotalAll Fees:S Check No. Check Amount: Cash Amount: 6. Total Project Cost: S i�©Q, 0 Paid in Full 0 Outstanding Balance Due: SECTION S: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) License Number ENtsiration Date Name olTSI.• I kidder List CSL rype(see below) ri De Description Address U Unrestricted(up to 35,000 Cu.Ft. R Restricted Ik2 Family Dwelling Signaturc M Masonry Only RC Residential Routing Covering felephone WS Residential Window and Sidin SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) 1110 Company Name or HIC Registrant Name Registration Number Address Expiration Date Signature Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.f 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 ..........0 No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 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. Siumaure of Owner Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION 1, �l/9E-A,g/ ,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. ( A/ oA r /7' Print Nam � �— Signature of Owner or Authorized Agent Date T Si ed under the gains and Penalties of '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 Ml have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.115,respectively. ?. 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 ). "Total Project Square Footage"may be substituted for"Total Project Cost" r CITY OF SUY. NI PUBLIC PROPERTY DEPARTMENT w,ro. 131)WADUPS, SMENT•3U+x MAUA04L MM 01970 r%L 975.74L9s9s • r-.%X 9'/•7409$4 HOMEOWNER LICENSE EXEMPTION Pkaw "I a Job Location 3WCe Home Owner Address /!�Z rQt4.1Z1EeSA[� Home Owom Telephone =- 3 17-- Present Mailing Address 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 Pesoo(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 stnutures accessory to such use and/or fano 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 p APPROVAL OF BUILDING INSPECTOR See other side for state code CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT I'.%.Iair... Ns I Wr a S.11,M.Vit.\•�q III -41..:1'1 I:C I rI' 'Iit.:J}'1V1� �1'\!f:'17t•i JJ'111K construction lDmuhi unDul posalIWAi work)refi In accurdaltce with the si-1111 edition of the date Duildin`Code, 790 CMR section 111.5 Dcbris. ind the provisions of MGL a 40. 5issu dacilit the debris resulting defined by MGL c puildiny Permit M _ • _ is issued with the conditiresulting li'om This wurk shall be disposed of in a properly licensed waste disposalY l 11. E1�/STi/ S 151 � 1A. /\/O pW#C> U7 �C00�. The debris will be transported by: t iurlM of hauler) 'I'lle debris will be disposed of in (Warns vl xl Iry i l;�►�s ut'r+rdilyl .gnalruf�/l ll.rmir+pyli�arlr Jale