BAKERS ISLAND - BUILDING INSPECTION (36) The Commonwealth of Massachusetts
Hoard of Building Regulations and Standards CITY OF
AM
Massachusetts State Building Code, 780 CMR Revise tf r 01
L,
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Fuutilt'Dvellittg
This Section For Official Use On
Building Permit Number: Date Applie ^_
Building Official(Print Name) Signal Date
SECTION 1:SI ION
L1 Pro ert Address• c ' I Assessors hlap.4r Parcel Numbers
(C5 15�Qn� AJCrA
I.1 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 It) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.GA.c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposals)s stem ❑
Public❑ Private El Zone:
if ycs❑ P P >'
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ow r of Recur G1 l ke-a A l O� V A � O Vgl ,T/
u�-IA . c k �, Y
;one(Print) City.Slate.ZIP
ql?- (P&q-3s95
No.and Street relephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ ExistiLBuilding❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accesdg. ❑ Number of Units Other ❑ Specify:Brizf Description of Prop sed • C.LULO lhJ
k
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Costa(Item 6)x multiplier x
3. Plumbing 2.List:
Fees: $ 0n, ,�/e
4, \lah:mical (II\'ACI S Lis[: (��`"�
5. .\Ie n t ical (Fire S Total All Fees: $
Su. ore-ionl
Check No. _Check Amount: —Balance
:\mount--_-_ -
6. Total Project Cost: $ a S b 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(C'SL)
License Numher lispiration Date
Name of C'Sl. l lulder
List CSI_1)pe(see below) _
Nu. and Street type Description
D Unrestricted(13uildin�s tio to 35,000 cu. It.)
City/I oft n,State,ZIP R Restricted I&?P:unil Dwellin+
M Mvon
RC' Booth C'overin
W'S Window and Sidin
SF Solid Fuel Burning Appliances
_ I lusulation
'fcle hone ('.mail address D Demolition
5.2 Registered home Improvement Contractor(HIC)
I IIC Company Name or I IIC Registrant Name I IIC Registration Numlx:r Expiration Date
No.and Street
Email address
Cl /Town, State,ZIP Telc hone
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
containe this app ication is true and accurate to the best of my knowledge and understanding,
I not ttner s or,4uhonze Agent's Nance(Electronic Signature) Date
NOTES:
[2.
An Owner who obtains a buildingpermit to do hisiher own work,or an owner who hires an unregistered contractor(not registered in the Home Improvement Contractor(HIC) Program),will nn!have access to the arbitrationprogram or guaranty fund under M.G.L. c. 1�1'_A.Other impunant information on the HIC Program can be found at
SoA oc:i Information on the Construction Supervisor License can be found at When substantial work is planned,provide the information below:
tal flour area Isy. R.) (including garage, finished basement'atucs.decks or porchoss living area(sq. ti.l __ Habitable room count
Number of fireplaces _ _ Number of bedrooms
NUltthe!of bathrooms
Number o(half`baths
1)pe of heating system__---------_--- Number of decks, porches------------
1}pe of emoting system —
_.._. . -------------__._._ Enclosed __Open
3 "Total Project Square Footage'may be substinned li+r"Total Project Cost"
CITY OF S.U.E.Nf
PUBLIC PROPERTY
DEPARTMENT
w. �
Vwraa 130WA"MGT011sneM 9 SAU^VwvAo&ssrnet9'e
1119'.671si9s"9 PAIL 978-740.904
HOMEOWNER LICENSE EXEMPTION
Flew "I
Date rP
Job Location
Home Owner Address - r
Home Owner Telephone
Presort Mailing Address .S GLLvn.e�
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
hire who.does not possess a license provided that the owner acts as supervisor.
DEFINITION OF HOIIQOV#?M
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
"Twmeowner"shall submit to the Building Official,on a fort 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 and raquarements.
HOMEOWNERS SIGNATURE ?f g AFL
APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF S.kL&Nf, LASSACHUSETFS
SLII.DLNG DEPARTMENT
130 W."HLNGTON STRM, 3i0 FZOOa
TM (978) 74S.959S
FAX(978) 740-980
Kl\CBEAIEY DRLSCOLL
NtAYOR THoues ST.PtEtan
Diltwroa OF PLHLIC PROPERTY/HLIIDLNG COMMISSIONER
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 Al is issued with the condition that the debris resulting from
this work shall be disposed of in a property licensed waste disposal facility as defined by MGL c
l 11, S 150A.
The/debris will be transported by:
(none of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit app icant
date
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