BAKERS ISLAND - BUILDING INSPECTION (39) 11�
The Commonwealth of Massachusetts
\ Board of Building Regulations ulations and Standards CITY OF WO
Massachusetts State Building Code, 730 CMR SALEM
Revised,Nnr 1011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only,
Building Permit No ber: Date Applied:
Building Official(Print Narruej, L, Sigmt, a Date -
SECTION (:.SITE INFORMATION'
I.I Property Address: 1.2 Assessors Map& Parcel Numbers
Tslcim 61 0o43
I.1a 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 @) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIPI'
2.1 Owner of Record:
. P E M,\IS _ k!a,9FN0N WT_ OL161a /RRty)N
City,State,ZIP
54 i�' ogy �T �0 —t/57-917`l ✓ IPS-ta IA-1 Ome7,9oa�l ,
No.mid Street telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
�iitA 1rl a I& x t 0 &x�
XSECTION L4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Itcm Official Use Only
Labor and Materials)
I. Building $ I. Building Permit Fee:$ 'Indicate how fee is determined:
❑Standard City/Town Application Fee .
2. Electrical $ ❑Total Project CosO(Item 6)x multiplier� x
3. Plumbing $ 2. Other Fees: $�
4.Mechanical (HVAC) S List:
5. Mechanical (Fire Suression) $ Total All Fees: $
Check No. Check Amount: Cash Amount
6. Total Project Cost: S � " oa 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES.
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL [[older
List CSL Type(see below)
No.and Street Type Description -
U Unrestricted(Buildings up to 35,000 cu.It.)
R Restricted 1&2 Family Dwelling
Cityrrown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
L
/Town,State,ZIPSECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.¢ 25C(6))
rkers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
s 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
'tq 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:OWNERS OR AUTHORIZED AGENT'DECLARATION
By entering my name below, 1 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.
X Print Owner's or Authorized Agent's Name(Electronic Signaatre) 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 NLG.L.c. I42A.Other important information on the H[C Program can be found at
www.mass.�uty."oca Information on the Construction Supervisor License can be found at www.mass.eov:/dps
2. When substantial work is planned,provide the information below:
Total Floor area(sq. ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
"Type or heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF S.V-&Nf
PUBLIC PROPERTY
DEPARTMENT .
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HONtEOWNER LICENSE E.U.NM10V
Pin" Mat
Date G 3
Job Location 9A T<I c n of
Home Owm Addmas 5-q pop .Sr � /y!a 7y962
H er omoOwrTelepbmo �f) 7- us 7- giiu
Plssese Mailing Address , 11 Ape s7 r eha n� YNn avna 7
no current exemption of"Homeowners"was extended to inch&"ow nar-occupied
dwsuin fs of twis Units or teas and to&Ww such homeowoees to engage an individual for
him who does lot possess a licenser,provided that the owner acts as superviaor.
DEFINMON Of HChMOWMM
Person(s) who owns a pared of Lod on which hdsM resides or intends to reside. an
which there is, or is intended to bv6 a one Of two Iftmily dweuing, attached or detached
itructUM accessory to such use and/or farm sgvotu va A person who constructs more
dun one home in a two year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building OQlcial, on a form acceptable to the Building
Ofllcial, that he/she be responsible for all such world performed under the Building
Permit
The undersipted "homeowner''named responsibility for compliance with the State
Building Code and other applicable by-laws usd ieguladons,
at undersigted "home0wT1""certitlea dial he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that hdshe
,vill comply with said proeedsuea and requirement&
HOMEOWNERS SrGNA TLRB
kPPROVAL OF SUILONG INSPECTOR
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