BAKERS ISLAND - BUILDING INSPECTION (13) The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
Massachusetts State Building Code. 780 CMR. 7"edition Building Dept
` Building Permit Application To Construct. Repair. Renovate Or Demolish a
One- or Tito-Furrri selling
This Section F r O tcial Use Onl
Building Permit Number: � r� �� D e A lied:
Signature: 4
Building Commissioner/Ins or o Buildings Date
SECTION 1: INFORMATION
LI PropeEy Address: 1.2 Assessors Map& Parcel Numbers
RSL_A)I � j°2AlSZ
Parcel Number
1.la Is this an accepted street?yes_ no Map Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(R)
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: f
` Zone: _ Outside Flood Zone? Municipal❑ On site disposal system O
Public❑ Private fJ Check if es❑
SECTION 2: PROPERTY OWNERSHIP[
2.1 Owner[of Record: `3� IJ
no r r�.ssel/ �o s3ox kI M�nches�er MA 0144
Name 1 t) Address for Service:
Sow 345.5�3 -7-7
Sign ure Telephone
SECTION l: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction❑];d
ingBuilding IIf Owner-Occupied ❑ Repairs(s) ISO Alteration(s) '6� Addition ❑Demolition ❑ ssory Bldg.❑ Number of Units_ Other O Specify:
Brief Description of Pr Work': S I
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimsled Costs: Official Use Only
Item Labor and Materials
I. Building f 0pQ 1. Building Permit Fee: f Indicate how fee is determined:
❑Standard City/Town Application Fee
2 Electrical S ❑Total Project Cost'(Item 6)x multiplier x
J. Plumbing S 2. Other Fees: f �/ n
4. Mechanical IHVAC) f Lise f
S Mechanical (Fire S Total All Fees: S
Suppression)
Check Na. _Check Amount: Cash Amount:_
6. Total Project Cost: S �� 000 ❑ Paid in Full ❑Outstanding Balance Due:
4
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
N;tma ul'CSL Hylder
A List CSL Type(we below)
Address Type I Desen non
U Unrestricted(up to 35.000 Cu. Ft.)
Signature R Resuictrd I&2 Famd Dwclhn
M slasonry Only
RC Residential Roofing Covering
Telephone w'S Residential Window and Siding
SF Residential Solid Fuel Elumin
jLApphance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 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 .......... O 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.
�] /J .O ! '
Si aturc o wner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declJand
that the statements and information on the foregoing application are true and accurate, to the best of my knowledg
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of peru
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 (he Home Improvement Contractor(HIC)Program),will 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 I IO.R6 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 half.-baths
Type of heating system Number of decks/porches
Tspe of cooling system Enclosed Open
3. "Total Pro)eci Square Footage"may he suhsmuted for 'Total Project Cost"
I'
CITY OF SALEM
PUBLIC PROPERTY
DEPARTIMENT
Kl]OklliY Nw.'.y L
Vwroa 13@w.munc."SMENr 9 s^uaa 4,UACHLW s019.0
T'EL 9711-745-9sss• t.Ax 978.7+aes4
HOMEOWNER LICENSE EXEMPTION
Please Print
Date `i, IJ• Of
lob Location 2>-AAers Zs)an d Lod Sal-em
me Owner Address F0 SAX 3`a0 ro �c�P✓ MA n19*
Home Owner Telephone a S"t • 3 4 S, 5 IR-I'7
Present Mailing Address PO 3ox iS) MA O I 2 7 \
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
hum who does not posses@ a license,provided that the owner act@ as supervisor.
DEFINMON OF HOMEOWNER
Persons) 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 O®cial,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 requirement&
HOMEOWNERS SIGAIATL'RE
APPROVAL OF BUILDI.YG , PIE:11Ra
See other side for state code