BAKERS ISLAND - BUILDING INSPECTION (34) 7 fhe C'unmwnsvc;lhh of Mussachuscus
Board ol'Building Regulations and Standards CITY OF
s s k1;Is.aachusetts State building Coda,79U('MR SALEM
Building Permit Application To Construct. Repair, Ronuvate Or Demolish a
One- or Tnn-Pirrrrilr Un ellhnq
This Section For 011ieial Use Onl
Building Permit Member. _ Date A plic
kos.. „ Lu TIZZ-(14• k t v
Iluiidiny 011icial tl'rinl N;une) i Dale
SECTION I:SITE 1 FORNIATION
I.I Property Address: 1.2 Assessurs .stap& Parcel Numbers 8
JT 8 PJQVM5 ESLANN5
I.la Is this an acce led street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dirt)enslons:
.—
Zuniny District Proposed the Lot Area(sq 11) Frontage(11)
1.4 Building Setbacks(R)
Frans Yard Side Yards Rvar Yard
Required Provided Required I'ruvided Required Provided
1.6 Water Supply:(M.G.I.c.40,154) 1.7 Flood Zone laformatlon: 1.3 Sewage Disposal System:
Ihrbllc D Privule O Zone: _ Outside Flood Zane? Municipal O On site disposal s)stem D
Check if usD
SECTION2: PROPERTY OWNERSHIP'
T0�R,rNA4-brJ GtLbcGEYJ
D Aw8lnay N H, 03a3o
-rums(Print) City.State.LIP
58 SE`AWARb hnzvE, qrM-SS7-lo'1q QAAErbL�@M5N
Nu.and Strcct relephone Email Address
SECTION]: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction D Existing Building( Osvner-Occupied JV Repairs(s)Q( Alteratlon(s) Addition D
Demolition D Accessory Bldg.D 1 Number of Unih� Other D Spcciry:
Brief Description of Proposed Work':
5V211:11" a PAIZobF ss�er(ertNrk
'P,�PLAU F"CEA
t (,ACC 700 WGNOaWS — SA .b.
SECTION 4: ESTIMATED CONSTRUCTION COSTS
hem Estimated Costs: Ofllclal Use Only
I L ahor and.\Iatrriais) y
I. Building S iq00o,M 1 1. Building Permit Fee: S Indicate how fee is determined:
2. 11wrical S D Standard City,Tussn Application Fee
D Total Project Cost'(hens 6).1 mulliplier
1 I'hunhiitg S — ?. Other Fees: S -
J. \Iech.usical ill\ \('t S List:
5 \lechanic.rl 1Fne
`u„resswnt S rotal All Fees: S
Check NO, ( hvek .\Ileum: Gish \mount:
I, Tulul Project Crest: S g ppp,pp p paid in Full -- D Outstanding Ilalmve Due:
Y' (,alit. i1•'6 D�A� � +.( .�. ,� �z��s
St.'( I[ON 5: CONS I-RlicrioN SFRVI( FS
5.1 Construction SuI)Qn isOr License I(SI-)
i Npiratwo {hotI coim:Number
Holder
I)Pit De"riplitin
II
litircstriciW(litull it, ski to35.000cu
It Restricted 1&2 F-1111il M%Vllill
('i10"mil.swiv./It, M Mason
KC Kkkiklin Uncrin
Ws window and stain
SF Solid Fact fluming Applianc"
I insulation
I hoot 1:111ail;Ijjrc%s D Donolition
5.2 Registered Home Improvement Contractor(IIIQ IIIC livilbiration Nurintivir h:cpinttiuFli-mg
I IIC C%j111pjn) Ninne tit I lIC It4gistrant Name
No. and Stm-01 Email 3jamss
Ciry/Town.State,ZIP rci )hone
SECTION M WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.Le. 152.1 25CM)
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 or the building permit.
Signed Affidavit Attached? Yes..........0 No...........CI
sFul-ION 7s:OWNER AUTHORIZATION TO BE COIIIP ETEDWHEN
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 Umier's Name(Elccirunic Signature) Date
SECTION 7b:OWNER AUTHORIZED AGENT DECLARATION
By entering try name below.I hereby attest under the pains and penalties of perjury that all of the information
contain in this appl�i^ca/ttigp istr and accurate to the best of My knowledge and understanding.
I-al-
l1rint 0%kncr'i or Aisth,lri/k: \9 I Hcctrtinic Sitinaturv) Mw
707ildr who obtains a building permit to do his her u%vn work,or an owner hires unregistered cunivictur
(not rev isttred in the Hume I mproveintrit Contractor I H IC I Program I,will LU) have access to the arbitration
program or guaraill) land under M.G.L. i:. 142A. Othcr important information on the HIC Program can be round at
111fornialicin on the Construction Supervisor License can be round at
%\J tJ':en substantial%�urk is planned,pro%ide the hilbrinntion bclo%v!
r or area 114. tl I including garage, 11mished basement attics.Jacks or rorchi
Cross lie ing area 154 it I Habitable room count
\umbviroffireplaces Number of bedrooms
\mnher ol'bathrooms \tJ111bVr ofliall,limlli
I\lie of 11c.1tilig 5%stein \1111iberot'dc"i,
porches
of:oohttg ' it% oll olicil
Tonal Proico Square ma) i1k: ,,h,ntuik;d 1kir ki(al Prili"t Cosy'
CITY OF S.ULE.NI
PUBLIC PROPERTY
DEPARn, iEIVT
Ufywrtirvy.
wvae ��aw�w�sruat•sk+rt ys�owasm oN-o
to+-s.r+sss+s•v..s:rar,o.sw
HOMEOWNER LICENSB EXE.MFTION
P1sw Fttlat
Date 051101t�-
!ob Location e A l "e, LS ua Np L a T' 8
HomeOsvnetAddresr _ .52 SEAwAA.r5 DAAU4E DANWAH AJO 03z3�0
Home Owner Telephone RN -E S17 —1 el)y
Present Marlin/Address 5A ME
The current exemption of"Homeowners^was extended to include ownw occupied
dwellings of two Units or less and to allow such homeowners to engage an individual for
hire who doss 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 reddss or intends to resids6 on
which than is, or is intended to be,a one or two family dwafts attached or detached
structures accessory to such use a dlor farm structures. A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeownear'shall submit to the Building Omcial,on a form acceptable to the Building
Oillciak 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 bylaws and regulations.
The undenigned "homeowner'certifies that helshe understands the City of Salem
Building Department minimum inspection procedures and requirements and that hNshe
vill comply with said procedures and requiremen
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING NSPECTOR
See other side for state code
CITY OF S,l[ Nrl AUS,WHUSETT'S
JLLLncvc OEp.IRT1t8\T
I'0 `JV.IiHf.YGTON STXW, }'a'FLOOR
` RL 1978) 14l.959f
!U1c3FRLBY ORLSCOLL FVt(973) 7447844
MAYOX MO.+W ST.PmU4
01a8CTOR O/PLSLIC PROPlRTY13L ULYC CONNISSIO.NEA
Construction Debris D13POs21 Attldavit
(required for all demolidoa and renovation work)
In accordance with the sixth edition of the State Building Code, 180 QNR section III.J
Debris, and the provisions of lNCL o 40, S 54;
Building Permit At is issued with the condition that the debris resulting from
11 work shall be disposed of in properly licemed
1
I 1 I, S I JOA. waste disposal facility as defined by,NICE o
The debris will be transported by:
ES-Sex . W S-aqA rtAYV
(name of haule)
The debris will be disposed of in :
(name of h�Y)
Ijddrnr al f�cihry)
+ynJNlsuf,erm pphcmt
Alta