BAKERS ISLAND - BUILDING INSPECTION (35) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR
SALEM
Reri.red.Ilan 2011
L,
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Ttvo-Fanfily Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied: ��
"ate
Building Official(Print Nine) Sign t e th
SECTION I:SITE INFORMATION
.I ertY Pro Addrtess: OOyssesso.2 Assessors Nlap& Pa cc[Numbers
p `��'
s+t ^
I.I a 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 ll) Frontage(ll)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Munici al ❑ On site disposals)s stem ❑
Public❑ Private❑ Check if yes❑ p P )
SECTION 2: PROPERTY OWNERSHIP'
�(,� /�v {'
.1 Owner[t[c Icordl* �1 ��,� �0v, Stvu �(rw��o�A / L� O/'T 1 J
N: e(P� � City'.State,ZIP ,
�'6 � �l4, alln)n')hC�g�af • co'•-,
No.and Street Telephone EmailAddress
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ I Repairs(s) ❑ Alteration(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Spccily:
Brief Description rof Propose Wofk':
64�� �ll n.ih / MG I7S� DOr� —nof f C
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building S 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ ? Other Fees: S
T. .Mechanical (IIVAC) S List:
5. ;Mechanical (Fire $ Total All Fees: S
Suppression)...
Check No. _Check Amount: Cash :\mount:,---
6. Total Project Cost: S -a d QQ 0 0 Paid in Full 0 Outstanding Balance Due:
SECTION ,5: CONSTRUCTIONSERVICES
5.1 Construction Supervisor License(CSL)
— _ License Number licpimlion Date
N:nna o(CS I. I IulJcr
List CSL l'ype(sec below) _
Nu. and Street Type Description
t/ I lnrestricted(Buildings uo l0 35,000 cu. ll.)
Citylrown,Slate.ZIP R Restricted I&2 I'mn it Dwelling
M Mason
RC Roulin C'ovcrin
WS Window and.' ,
SF Solid Fuel Burning Appliances
I Insulation
Telc hone ['mail address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Nance or I IIC Registrant Nance I IIC Registration Number lispiruliun Datc
Nu.and Street
Email address
City/Town, State,ZIP Telc hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 4 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 CONIPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property,hereby authorize
act on Ty behalf,in all matters elatrve to work authorized by this building permit application.
I not Owners Nance(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.
Print Owner's or Authorized Agent's Name(Flecuonic Siglmture) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an own=og
nregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program).will no the arbitrationprogram or guaranty fund under M.G.L.c. 142A. Other important informatiogram can be hound at
L;ov oc5 i Information on the Construction Supervisor License canrv,nla c� o._'Jps
_' When substantial work is planned, provide the information below:
Total floor area(sq. R.) (including garage, finished basennent'anics, decks or porch)
Gross living area(sq. It.) _ Habitable room count
Number offireplaces __ __ Numberofbedroonts
Number of bathrooms ----- ----------
----------____--- Number ofhalE'baths
1)po of heating system ---------
---...---_-___.-- Number of decks, ---- -------------
pe of tooling s)slem Enclosed Open
i. Total Project Square Footage-stay be substituted for-rota1 Project Cost..
CITY OF S UX.NI
PUBLIC PROPERTY
DEPARTMENT
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HOMEOWNER LICENSE EXE..WffI0X
Please Ftlet
Date 13
Job Locatim
Home Owner Admeaa
Home Owner Telephone 2
Present Mailing Address
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or lean and to allow such homeowners to engage an individual for
hire who does not possess a 6cenA provided that the owner acts as supervisor.
DEFINMON 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 dwellin&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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures andrwouiremcritt.
HOMEOWNERS SIGNATURE
,APPROVAL OF BUILDING INSPECTOR
See other side for state code