BAKERS ISLAND - BUILDING INSPECTION (30) The Commonwealth of assachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application 'fo Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Only
Building Permit Number: Date pplied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
LIP er AJJress: �, 1.2 Assessors Map& Parcel Numbe��
1.I a Is this an accepted street?yes no__X Map Nta ber Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: /
Zoning District Proposed Use Lot Area(sq B) Frontage(II)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
/V N�q- I / 6'CD
1.6 Water Supply:(M.61 c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?
Public❑ Private — Check iryes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 A�qrl of Record:
' � �L�// A/!Z/1717t t7ah �t
Nan le(Print) City,State,ZIP
/, �,?k65 -S� 9V-0W6S7-P Y.3
No.and Snect Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction ❑ Existing Building Owner-Occupied I Repairs(s) ❑ Alleration(s) ❑ Addition
Demolition ❑ Accessory Bldg. El Number ofUnits__L_ Other ❑ Specify:
Brief Description of Proposed work':
s" m's
CO
SECTION 4: ESTIMATED CONSK RUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building $ ap I. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $
❑Total Project Cost'(Item 6)x multiplier s
3. Plumbing $ 2. Other Fees: $ h�
d. Mechanical (IIVAC) $ I,ts[: o `
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6, Total Pro
.jcct Cost $ -Ob ❑ Paid in Full ❑Outstanding Balance Due:
(PA J,Z-0 j T72' N k� O- W iLM,tJ6ZOtJ S�Z8
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Namc of CSL Holder
List CSL"type(see below)
No.and Street Type Description
U Unrestricted 6uildin s up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
Cilylfown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Dale
HIC Company Name or I IIC 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
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.
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 accur to to th best of my knowledge and understanding.
Print Owner's or Authori/ed Agent's Name(F,ectr is Signature) Date
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.eov/oca Information on the Construction Supervisor License can be found at www.ntass.gov/dps
2. When substantial work is planned, provide the information below:
"fetal floor area(sq. ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. If.) I-Iabitable 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. "Dotal Project Square Footage" may be substituted for"Total Project Cost"
CITY OF SALEM, MASSACH NSETTS
, ) BUILDING DEPARTMENT
120 WASHNGTON STREET,3110 FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KINIBERLEY DRISCOU
MAYOR THOMAS STTIERRE
DIRECPOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date ''3/ � /��/ ry9 \
Job Location /�11yay6 Lo � 9� /W/1CL�IS "�r__�//? /� e
Home Owner Address DII;r164S ST zti ni-, 471 n / aft) 7
Present Mailing Address 5//,Me
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 that 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 understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR
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Commonwealth of Massachusetts
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120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 x5641 uV
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Return card to Building Division for Certificate of Occupancy
Permit No. B-14-959IN
FEE PAID: $25.00 PERMIT TO OwILD
DATE ISSUED: 5/27/2014
This certifies that GOLDEN PETER/GOLDEN KATHERINE GOLDEN
has permission to erect, alter, or demolish a building 0 BAKERS ISLAND Map/Lot: 460091-0
as follows: Renovation ADD DECK TO EXISTING PORCH ON SOUTH SIDE OF HOUSE
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Contractor Name: 4=t5
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DBA: �
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Contractor License No: 4l t t
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�� �a 5/27/2014
t �, tt,nBulldl,npg Official Date
'-�tic�5 _ �� `.>r ,,..``4'��• .,..,.4, hE��.. ....
This permit shall be deemed abandoned and invalid unlesathe work authoriied'tiy this permit is commenced within six months after issuance.The Building Official
may grant one or more extensions not to exceed six myo..nths each upon wntten reques?�t, �' r f
All work authorized by this permit shall conform to the approved application and the approved construction documents for whMh.his permit has been granted.
All construction,alterations and changes of use of any budding and structures shall be in compliance with the local zoning by-laws and codes.
This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the
work until the completion of the same. lie' `
The Certificate of Occupancy will not be issued until all.applicable signatures by the Building and Fire Officials are provided on this permit.
H IC#: Persons contracting with unregistered contractors do not have access to the guaranty fund"(as set forth in MGL c.142A).
EPM+'j' t- FA°g MOM,
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Restrictions: W.
' 5 x y'S1 �� � '
¢
Building plans are to be available on site.
All Permit Cards are the property of the PROPERTY OWNER.