BAKERS ISLAND - BUILDING INSPECTION (16) j'� The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,.Repair,Renovate..Or Demolish a
I' One_or Two-Family!Dwelling
U This Section For Official Use Only
Building Permit Number: Dar Applied: /
Building Official(Print Name) Signature Date
SECTIONI: SITE INFORMATION
1.1 Property Address: 1.2.Assessors.Map&Parcel Numbers
=-C S E5LAN0 Lo-r �* B
l.la Is this an accepted street?yes_ no Map.Number Parcel Number
1.3 Zonin Information: 1.4 roperty Dimensions:
NIA t — d,UOA>
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
be"AnAT t DANFiURy 1N44 01A30
Name(Print) City,State,
!i$ s'rAW-kn-D -De. C(%-85`1 -16% PM(:r D N(2 MSN .com
No.and Street - Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction t7 Existing Building)dOwner-Occupied M Repairs(s) 0 1 Alteration(s) A I Addition IQ
Demolition ❑ Accessory Bldg. ❑ Number of Units. I Other ❑ Specify:
Brief Description of Proposed Work': Wc- DEGIG CXLSTrn1Cr 46C1eStST-AL64s.
SIZCrttTlY tWL44r.C1(_ J/WNT STAr1LS REPI.Ac.C. TwL-c-E Ekr,<eTZNLr UItollaWS.
Rf Pt_ac� LATTLct_ Trr.P_M AILor kjb G6T)ALsE
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ rl o OQ,00f2.
Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ �- Standard City/Town Application Fee
Total Project Cost (Item 6)x multiplier x
3.Plumbing $ Other Fees: $
4.Mechanical (FIVAC) $ —� st:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 7 000.w 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwell in
City/Town,State,ZIP M Masonry
RC Roofin Coverin
WS . Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolitio
5.2 Registered Rome provement Contractor(HIC)
Registration Number Expiration Date
HIC Company Name or HIC Reg ant Name
No.and Street Email address
City/Town,State,ZIP Telco e
SECTION 6: WORKERS'COMPENSA NSURANCE AFFIDAVIT(M.G.L,c. 152. § 25C(6))
Workers Compensation Insurance affidavit must comp ed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Is s ce of the bu' ing permit.
Signed Affidavit Attached? Yes ....... .. ❑ No.......... ❑
SECTION 7a:OW ER AUTHORIZATION T E COMPLETED WHEN
OWNER'S AGE OR CONTRACTOR APPLIES PQR BUILDING PERMIT
1,as Owner of the subject pr/Opers
hereby authorize
to act on my behalf,in alllative to work authorized by this building permit lic
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below,I 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.
0 a I
Print Own&Js or Authorized Agent's Name(Electronic Signature) Dine
NOTES:
1. 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 not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found atM3nv.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor 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
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
1 1
CITY OF Si1LE.NM) A-"SACHUSETTS
BI;tLDLNG DEP.1RT1tE,YT
120 WASHNGTON STREET, 3A°F_AOR
' TEL (978) 745-9595
;<iSCDERL3rY DRISCOLL F-1,Y(978) 7-W-93.14
llb boll T�to+us Sr.PtsRas
DIRECTOR OF PC BLIC PROPERTY/SL MDLYG CONNISSIO:i ER
Construction Debris Disposal Aftldavit
(required 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 NM c 40, S 54;
Building Permit I# is issued with the condition that the debris resulting from
this work shall bo disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11, S 150A.
The debris will be transported by;
N LA
(name Unlaulur)
The debris will be disposed of in
O .fl .DCC.1r.P.njG — F71t, -
(name of racility) _
(address ur(11:11ity)
5 jn re ufpermit applicant
date —
II
CITY OF S.U-FNf
PUBLIC PROPERTY
DEPARTMENT
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rti rsrssss•t •v..a.r.tir,osw
HOMEOWNER LICLNSS EXY.It MON
Ptew lrist
Dots
lob Loeados Ak-", txANb LOT-
HomeOwosrAdda+w SR o& BAN d2,N kJ o3Z3o
Home Owoer Telephone CI?C— S-- — I o7L(
Present Meiling Address S mZ'
no current exemption of Homeowners"was extended to inchtde ownar-occupied
dwellings of two Units or fen ad to allow such homeowasre to engsgs an individual for
him who does xot possess a licensa provided that the owner acts"superv{soe:
DEFINMON OF HOMEOWNER
Person(s) who owns a panes)of land on which hdshe asides or[ataxia to reside, on
which there[q or is intended to bs,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 OQlcilk on a form acceptable to the Building
0111ciai, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner'asaumes responsibility for compliance with the State
Building Code and other applicable bylaws and regulations:
no undersigned "homeowner"certifies that hdshe undentands the City of Sal
Building Department minimum inspection procedures and requirements and that e/she
.Vill comply with said procedures and requirements,
HOMEOWNERS SIGNATLW —4 .
APPROVAL OF 8U1LDIVG LYSPECTOR
See other side For state code