BAKERS ISLAND - BUILDING INSPECTION (10) The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR. T"edition
i� Building Dept
Building Permit Application To Const , novate Or Demolish a �
One- or �-Family Duelling
7 is Section,For Official Use nl
Building Permit Num ate A pli .
Signature: c) Q
Building Commtsvoner/Ins for of ings ate
SECTION 1: SITE INFORMATION
1.1 P ernfy, Addc J O 1.2 Assessors Map S Parcel Numbers
70) o Jr [,fe.l�
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 fl) Frontage(it)
1.5 *Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40.154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ 1 Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if es❑
/^� SECTION 2: PROPERTY OWNERSHIP'
2r gwner'S of "or f: '/" Z7- P�, 3,
r
Name(Print1-7
—� Address for Service:
7 �j- Y72- 2Si 9
Signatube Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
B 'ef scription of p posedd Wo '
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OMcial Use Only
Labor and Materials
I. Building f /Ur 0&0 I. Building Permit Fee: f Indicate how fee is determined:
❑Standard City/Town Application Fee
2 Electrical f ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing f 2. Other Fees: f
4. Mechanical (HVAC) f List:
5 Mechanical (Fire f
Total All Fees: S
Su ression
Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: f ❑ Paid in Full O Outstanding Balance Due:
'rl
f
)
SECTIONS: CONSTRUCTION SERVICES
fS.,].'LLice/ns dd Construction Supervisor(CSL) 6 l4y/l0%'cr�" L��,/�`+ License Number Expiration Date
Nf1me Of CSL- iglder List CSL Type lxw Iwlow) f
6 5 qs-
r Description
Address I� ^� U Unrestricted u to 35.000 Cu. Ft.) 'r
w �on CAP s�er OI q-70 R Restricted 1&2 FamilyDwellingt
Signature .N Mason Only
RC Residential[ Roofin andCovering
Tdephane w5 Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Register 1 me 1 rove en Co Tctor(HIC)
HIC Company a t r HIC s �N Regtstrati u
r
��
Address 83 Ex irmid ate
S Telephoneignaru
a
SECTION 6:WO SATION INSURANCE AFFIDAVIT(M.G.L.e. 152. 2SC(6))
Workers Compensation Insurance affidavit must be completed and submitted with this a lication. F ilure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... O No...........O
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.
Signature of Owner Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
1 , as Owner or Authorized Agent hereby declare
that the statements and 'nfornation on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
It
Prinr Name ��
Signature of Owrffr or ut otzed Date
Maned under the pains and penalties of perjuryl
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 ell have access to the arbitration
program or guaranty fund under M.G.L. c. 1 J2A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I IO.RS.respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basementlattics, 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 he substituted for"Total Project Cost"
e
CITY OF SALEM
r
PUBLIC PRc)PRERTY
DEPAR f'MENT
Construction Debris Disposal Al•Iida- it
(rciluired fi)r all demo Iition and renovation work)
In accurdancc all the sixth edition of the State Building Code, 780 CMR section I 11 5
Debris, and the provisions uf'v1GL e 40, S 54;
Building Permit K is issued with the condition that the debris resulting from
this work shall he disposed of in a pruperly licensed waste disposal facility as defined by IAGL c
I11. S 150A.
The debris will be tran,ported by:
I OJNC ut hauler)
I he debris will be disposed ofin
(OdInC d laclllt Vl
I•uldre.. of gcllityl
aulJlwe nt p:nnu JlryihcJnt
.I JI•
CITY OF SALE.tii
PUBLIC PROPERTY
D EPARTII iMNT
K1.alkurY
MAVOM 130 WAMPwro"STRENT 0&UAK UAMACHLSE is 019-0
TEL r..3-74.95"* P.ac 978.740.994
HOMEOWNER LICENSE EXE.MMON
Plea" Print
Date r7 2/ 0
,ob Location SAL s J—S)fp `"
Home Owner Address
Home Owner Telephone S'/ 4
Present Mailing Address L*nC � MA-
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 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 fora 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
APPROVAL OF BUILDING INSPECTOR
See other side for state code