BAKERS ISLAND - BUILDING INSPECTION (14) The (lnnnumwrulth of IWJSSJihuseIIS —�— — —
i .. it r I300111 uF I3mlding IZrgula(ions and StmnJ:uJs I t ll(
t r' Massachusetts State Building Code. 7S1) ('MR, 7"'edition \II NIl'it, \1 I I 1
Building Permit Application To Construct. Repair. Renosate Or Demolish a R„„rJ.l,nn, l„
p� (Arc- or Tlru-l•imtih Dlrrllin,i
phis Section Fur Otr eiat Use Only - --3
Building Permit Nun era Date Applied:
Signature:
&ul me Commm Inoprrlur ul Buddnlgs Umr
SECTION I: SITE INFORMATION -- —
1.1 Property Address:X 1.2 Assessors Map & Parcel Numbers_ - -- -----I I:; Is This an accepted treet7 ves nu_ Map Number P.ucrf ,\umhrr —�
!n ormation:
Ld Property Dlniensiuns:
Zan r la rt Pn;pc ,J I ._ t � \.- a Ism Iii Fl onmuc I III .
i.S Building Setbacks Ift)
Front Yard .time Yards
— _ Rear l;:rd
Re mired Provided
III .____ d Rcymrcd Yruvi=ccl Rcyu�rcd �— Pro,idcd
1.6 Water:iupply: tM.G.L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage !}isptsal System:
Public ❑ Private❑ Zone: -_ Outside Flood Zonel
I— Check it yes❑ Municipal ❑ On site dhposal systnnl ❑
SECTION 1: PROPERTY OWNERSIHPt
r2.1 Ownert Record: --
, .-�wQ Pru;tl - 2-F�S� CAP Lit SZ� Lp lL
:\ddres�s7 for Srry ice: Al C-rf UeA-) O10�7 f
ti gn:.tmre Tclephome
SECTION 3: DESCRIPTION OF PROPOSED WORKz!check all that al;,.!v)
----- ------T —New Construction ❑ Esisitine Building, Owner-Occupied y� I Rrpmrs(s) ❑ 1 Alterationls) ❑ Addnunt
Demuli;i:ro ❑ Accessary Bldg. ❑ - Number of Units_� her ❑ Speclly.
— -- 1 Brief Descr.puon of Proposed Work-:—
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Fsiimated Costs:
ILahor and Materials) Official Use Only
j i. 13 ine g L Budding Permit Fee: 5 2� IndicJte haw tcc a delernnllcJ
?. Electrical
S ❑ Standard City/Town Application Fee
❑ Total Project Cost' (Item 0) s multiplier s _
1 Plumbing S ? Other Fees: 'S
-- I
4. :'i,fechameal tHVAC) 5 List:
S. Mechanical IFire I
Su i iressi,m) 5 Total All Fees: S '2�� __ ----------- f
------I Check �Vu. C heck amnum: CaIh. :\m„unl: 1 o. Total Project Cost S �7
I'll ❑ Paid In Full ❑ Ornst•In1ling Bal.mce Line.
It
it
SECTION 5: CONSTRUCTION SERVICES -�
4
5.1 Licensed Construction Supervisor fC'SIJ
L,rcmc Number I`ynrnuun Ualr
_ �I
--
' \aloe of C'SL� IIuIJer l_u1 C51_ fNpe„cr heloe t --- +
-I-N, DaNcn ,uun —�
\Jdre,s 1. L'nrrxnrlyd up to 15,(000 Co. I 1
R RrunrteJ LNc' F.muIN ONN ellinc --�
ii_n:pure \1 \Isom\ Onlc
RC Rcs,Jrnlul Huullnc('menn`_ —
\CS He„d:nual \1'i lido,, .inJ _-
1'elrPhune
�F' Re,iJeoual .Solid Fuel IAu num \I+PL.wr; In,,.lLnn ai ,
p H.•„Jenual Deo,ahu,al _--1
5.2 Registered Home Improvement Contractor 0111C)
Reeulrauun Nun,her
HIC Company Name or HIC Registrant Namc
\Jdre,, Fy,uution Dal: --
Telephunc
Signature
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. 5 25QM6
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to pn,N ide
this affidavit will result in the denial of the Issuance of the building permit.
Sined Affidavit Attached'? Yes .......... ❑
No -
t, ......... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
1. _-_---.-- to act on my behalf. in all "tatters
authurite
relative to w,>,k authorized by this building permit application.
-------' Date ----- --
Si nature of Owner
SECTION 7b: OWNERt OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
I,
mmatiun on the foregoing application are true and accurate, to the best of my knowledge and
that the statements and info
behalf.
Print Name —�
Dale
Signature of n
f 0-Owner or :\uthonzcd Agcnl
ISi lied under the p❑ins and Cenalties of cegu
1. An Owner who obtains a building permit to do his/her own \Nork,or an owner who hires an unre�a,tercd ctmtru�lor
(nut registered in the Hume Improvement Contractor (HIC) Program 1, will not have access to the ubitrautm
Ht(' Program and
program or guaranty fund under M.G.L. c. la'_A. Other important inf a malion on the
Construction Supervisor Licensing (CSL)can be found in 780 (ANIR Regulations I MRG and 1 IO.RS. respecilscl\'
lal work is tanned, provide the information below:
When ,ubs(anl P d basement/utics, decks ur )orch,
Total floors area(Sq. Ft.I I including garage. firoom — ---
Habitable room room
Gross living area ISq. Ft.) Number of bedro„ms —----—Number of tueplaces Number of
I Number of hathmonts Number M darks/ pnrnccN
f%pe of heating NN•Ntem -- GnrloscJ --
T�pe of c„ol,ng NNNIem -
1. 'Total Project Square Footage" may' be substituted tar "Focal Pmler( CoNt�
r� %�� CITY OF SALEM
y a. t
>'
RP
PUBLIC PROPRERTY
DEPARTMENT
,:J\I C:-h LIvS i•Ii I'i,.i'.I I.
I_G U'Ai11IVGl ON 5'rltrasT * $.\I I'\1, \L\tii:\CIIl51 I"IS VI`.
'I'ISL: 978-74 9;95 ♦ 1':\S:978-740`9846
Construction Debris Disposal Affidavit
(reeiuired for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CNIR 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
1 11, S 150A.
The debris will be transported by:
, A� L�L,�zt�
tname of hauler)
The debris will be disposed of in
(name of facility)
(address of I'aci Iity)
signature of permit a icant
ate
drbri:�iLduc
CITY OF $mmm
PUBLIC PROPERTY
DEPARTmENT
K1f01ELw ivw•ry
I2G W& NGTON Sit•SAUMK N SLACHL mt 01970
TO-979-74S-9S"0 FAx 978-740.96"
HOMEOWNER LICENSE EXEMM'ION
Please Print
Date6U
Job Location i�A Ic �t'z s �I—r"►J�
Home Owner Address C�1 c o
Home Owner Telephone
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.
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 understands the City of Salem
Building Department minimum ' 'on procedure/ and requirem is and that hels
will comply with said procedures and req ements
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code