BAKERS ISLAND - BUILDING INSPECTION (22) ICs The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY�
Massachusetts State Building Code, 780 CMR S`UV j Revisedd Mar
Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Family Dwelling
This Section For Offic' se Only
Building Permit Number: I D Applied:
� r3
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property.,3�gddress: 1.2 Assessors Map& Parcel Numbers
paKG> f1 Y6 do 73*
Lla 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 R) Frontage(R)
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:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑ p P y
-- SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
bwtEL a Jvaso,u or,e
\ Name(Print) City,State,ZIP y
lC � � Iss�N sT 9 113 a a�.sason&Caw4 'f
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK''(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of(Jnits -- I Other ❑ Specify:
Brief Description of Proposed Work': Jet 'ALAGe'f `y4j�NALT S �`l e1�6G� t2�
SECTION 4: ESTIMATED.CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials -
l. Building $ p 6,pp 1. 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 $ 2. Other Fees: $ -
4. Mechanical (HVAC) $ List: -
5. Mechanical (Fire $'Suression) Total All Fees: $ _ -
Check No. Check Amount: ` Cash Amount:
6. Total Project Cost: $ 8010 C- DU 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 I&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
MC Registration Number Expiration Date
MC Company Name or HIC Registrant Name
No.and Street Email address
City/Town, State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 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 .......... ❑ No ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW 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.
�Pw5 _ (e.-JJDS� C/r3�17
Prin caner or Authorized Agent's Name(Electronic Signature) L Da[e
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.Qov/oca Information on the Construction Supervisor License can be found at www.niass.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"may be substituted for"Total Project Cost"
1
CITY OF SAI..ENI, TNLxSSACHUSETTS
BuELDLNG DEPARTMENT
• N• 130 WASHNGTON STREET, 3w FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
IcLNIB Rr FY DRISCOLL
MAYORIto+tAs ST.PtERAB
DIRECTOR OF PUBLIC PROPERTY/Bu .DNG C016NISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR 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
111, S 150A.
The debris will be transported by:
C. ase-VP W!:-�
(name of hauler)
The debris will be disposed of in
(`name of facility)
rPo1-.6Adr Mk
(Address of facility)
signature of pergVt applicant
7 l3
date
dcbrivft'.daa
CITY OF SM-EM
PUBLIC PROPERTY
DEPAM. LENT
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HOMEOWNER LICLNSR EXE.tiMPTI0jN
P1ew hiet
Date V t 3
Job Location T.*)rfun-s rd 1,A/NiJ MOF 4 e, t L a T an
Home Owns Addreae 3.2 0144kW Cr 1;y{�¢tg� ?vlsj a f9l g
Homs Owner Telephone 9-;-8 3 ES 4"f s;;6
Ptessot Mailing Address sr rC a l a/Aso ;2, A tVa y,
The current exemption of"Homeowners"was extended to include owner-occupied
daeUings odtwo Units or leas and to allow sreb homeownees to engage an individual for
him who does not possess a licensed provided that the owner acts as supervisor.
DF. INMON Of HOMEOWNER
Person(s) who owns a parcel o[Lnd cis which hdshe resldae or intends to resider on
which them ier or is intended to bsr a one or two faWly,dweWng, attached or detached
struetures 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 torus acceptable to the Building
Official, that hdshe 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 bylaws and rejulationa
The undersigned "homewwrice certifies that he/she understands the City of Salem
Building Department minimurn inspection procedures and requirements and that he/she
Will comply with said procedures and requirements.
HOMEOWNERS SIGNATLW � A ,
.APPROVAL OF SUILDIYG MPECTOR
See other side far stale code
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