BAKERS ISLAND - BUILDING INSPECTION (27) � l
_ I Ile CUI11111011%veallh of Mas)a0luselts -
i, .A hoard ut'I)uilding Regulations and Standards Cl I1' OF
Massachusetts State Building Code,-780 CbIR SALEM
Building Permit Applicatian 'ro Construct. Repair, Renovate Or Demolish a
II Unc-or Tun-Piunilr Du,•lligl(
This Section For 011icial 1 Onl
Building Permit Number. Date A plied: v Z
liwldins 01171cial(Print Nwne) Signature 1)
SECTION 1: SITE INFORI11AT1
L
1 Properry,A_ddress: 11AssessursJlap di Parcel Numbers
I�f-1 nee ) s(,i4r`+ba b this an accepted street? •a no AL1p Numhar Purcel Number
1.3 Zoning Information: 1.4 Property Dlmenslons:
Coning District Imposed ilia Lot Area(sq 11) Frontuga 00
1.5 Building Setbacks(R)
Front Yard Side Yams Rear Yard
Required I'mvidud Required Provided Required Provided
1.6 Water Supply:IM.G/.I.e. 40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
I IMI:❑ Private 01 Zone Outside Flood Zone?
Chock if a❑ Munieipsl❑ On site disposal s)stem Q,
SECTION(: PROPERTY OWNERSHIP'
].1 Owners of Records
es S fl
N;wsa IPmnl City.Slate.ur
CoS E 1A IA- e8ld 099-q91-18 .5 WL'S�1nMS011@�i►wn(l. CeVH
No.;mJ Street relephone Email A dress --
SECTION!: DESCRIPT 11 ION OF PROPOSED WORK'(check all that apply)
New Construction❑ E.xisting Building❑ Owner-Occupied ❑ Repairsls) Ah....1-- ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Speciryi
Brief Description of Proposed 1V�1ork':
f•�N%r1 CPO n Ar{-� Lo r r r St s
SECTION 4: ESTIMATED CONSTRUCTION COSTS
ltalll Estimated Costs:
I Labor and.MLterlalsl OITlclal Use Only
I. Building S 11,00 6 1. Building permit Fee: S Indicate how Foe is determined:
1 `. FIvorwal S ❑Standard Ciry:Tuwn Application Fee
t I'lumh;ng S ❑Tutal Project Costs(Item 6)x multiplier
_. Other Fees: S
� 4. \Ic.hunic.11 111\ \('1 S List:
5 \Icch.ulic.d IF1re
Cat „10Sianl S rufal .\II Fccs: S_
n Tidal Project Cost: S (hcd \'o, _Check AnunIIII:
( Zr Q 00 ❑Pail 1n Full ❑Outstanding B.d.usce Due:
f
Sr.('*l[ON 14:
I TFddcr I ist L'SL 1** Fle i1cc
I PC
14o 11id Street
It
RC Rmlil"I COW nit
S willUMV Inu 11UMM
SF SaliJ I-ugl Ilurning A�Ippliallcds
o n
Insulation
inailaddirv.xi ----------
lid 111olic ovement CuIllf"1001'("IC)
.1.2 Registered Home mpr --- 1:\Piralioll Date
I IIC Rvillit r ration Nimillic
Iliccollipill) Ndlpeor I IIC Registrant NJIMJ
I:mail address
U. mid Street
frown.state ZIP Tek hung
Cityll !L:L�
SECTION M WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152.1 2SC(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this atYIdavit will result in the denial of the issuance of the building permit.
yes.......... 13 No...........(3
Signed A Mdavit Attached? --- M
SECTION 78:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S '^MVoAJ-TnM 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,
�Mte
ii—rTia-0;7"r's—N,"'(Electronic Signature)
SECTION 7b:OWNERt OR AUTHORIZED AGENT DECLARATION�
By entering my name below, I hereby attest under the ai a and penalties of perjury that all of the information
Contained in this application is true and accu . t I e t of my knowledge and understanding.
)QL, ze( Z—
U'L--Su5Y Date
Prim Uw.......... . Name 11:1vctrolli0igna tire)
. 'rES. istered contractor
I .\n Owner %Ou obtains a building permit to do his.htr own work,or an owner who hires an ullreg
I lot registered in the Hume IMPI'Ove'llent Contractor(H IC) Program),will LU) have access to the arbitration
program or guarani) Nod under.\I.G.L.C. 14I.A. Other important information on the HIC Program can be roulld 31
Wkl% .% ,, I Information an the Construction Supervisor License can be round at tt tt.t M3,
2. \\lien substantial\surk is piallnud, prosiJe the informati on below:
e. t ase illcujillg gjrag1mished bment M ".I' Jerks or pordo
rotal lloor area 1'4. Habitable routil count
(Irt)jj It%ilig area i iq. It Ntilliber ot'hedrooms
Nkilliber ofli'llf haths
NkIlliber t,I hathrounis N11111hvr of decks, liordics
I)pc of healing 3)sett01'cn
I I":ol':oolllltL i%'IctlI
I oial Project 1;%luarc cd t1or-koal llroiM Co,t
. ti.
CITY OF S.UzNf, 4%LUS.1CHUSETTS
JuLDLNG OEP.IAT?tL.4r
110 `J AAA NGTON ST11jr, jid FZOCt
k978) 741-9591
!U 1�FJtL6Y D RLSCO[.L
FAX(973) 140.9&id
N(AYOA mcis tST.PMAAA
O1it=c it O P PL 8UC PROPII<TY/sL MnLNC CO1011331ON E 1(
Construction Debris Disposal At'tldavit
(required for all demolition and renovation work)
In accordance r with the sixth edition of the State Building Code, 790 CaMR section I I L J
Oubria, and the provisions of,MGL a 40, 3 34;
Building g Permit At is issued with the condition that the debris resulting from
111 work shall be disposed of in a properly licemed waste disposal facility as defined by NIGL c
Ill, $ I JOA.
The debris will be transported by:
(nuns ul Pauly)
The debris will be diissp_osped- of in :
I�ddrea orr�rihiy)
u�n�Nro of permit rpph.rnf
CITY OF SM-E.NI
PUBLIC PROPERTY
DEPARTMENT
a�.u.aas�oasu�u
Vwwe IDWUDWNGWW*W=•sA AK VAoJhowram01re
ML Y/tls 7sf! •FAA rtL7+69w
HOMEOWNER LICLNSB EXBM"10N
P1taw Mat
Data I Jl SU L- 20Iv
lob Laad n
Home Owner Addreaa Inc f-4t C t-, sac»
Home owner Telephone '
Prelenl Mailing Addrew
The current exemption of"Homeowners"was extended to include ownaroccupied
dwellings of two Units or teas and to allow such homeowners to eagags an individual for
hire who does not poaaew a license4 provided that the owner acts as supervisor.
DEFINMON Or HOMEOWNER
Persons) who owns a parcel of farad on which he/she reaidea or intends to reside. on
which then i; or is intended to be, a one or two family dweWnS attached or detached
structures accessary 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 00144 on a form acceptable to the Building
Official, that he/she be responsible for all such wort performed under the Building
Pamir
The undersigned "homeowner"asrumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner'certiAa that he/she understands the City of Salem
Building Department minimum inspection p ures and requirements and that he/she
.vile comply with said procedures and requirem
HOMEOWNERS SIGNATURE
.APPROVAL OF BUILDING NSPECTOR
See other side for state code