BAKERS ISLAND - BUILDING INSPECTION (40) �I The Commonwealth of Massachusctts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 C'MR, 7'edition OF SALEM
"'www Revised Jmmurr
Building Permit Application To Construct, Repair, Renovate Or Demolish a /. :WAV
l y One-o wu- milP Dwelling
a Lion for Official Use Only
Building Permit Num r: en Date Applied:
Signature: 21 A
Ruildirig C iaioner!Impectar o B Idin Date
SEC NON I:SITE INFORMATION
k16
perty Address: 1.2 Assesson Map& Parcel Numbers
V ��rc ZSI ar) d �lr, n Yam ) �(
this an accepted street?yes no Map Number Parcel Number
Zoning Information: IA Property Dlmmsloor.
� 34"1_5'F. S?to`fistrict Proposed Use Lot Am(sq It) Frontage(11)
lding Setbacks(R)
Front Yard Side Yards Rear Yard
ired Provided Required Provided Required Provided
er Supply:(M.G.L c.4a,§54) 1.7 Flood Taue laformatloo: t.8 Sewage Dbposal System:
Private O Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑
Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
�rc �o� lnJ . .,ss e)( r �3ox _ Sea fy\Q A,n,eS-�Qx -MA �19 y`�'
XName(Print) Address for Service:
SO 8 • .345 • .S a-lZ
Sign Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) ❑ TAlteration(s) Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
gEle"c(riC211
Estimated Costs: 011lcld Use Only
Labor and Materials
Building S (o I. Building Permit Fee: f Indicate how fee is determined:
cal S ❑Standard City/Town Application Fee
❑Total Project Cost(Item 6)x multiplier x
ing S 2. Other Fees: S
nical (IIVAC► S List:
ical (Fire Son Total All Fees:S
roject Cosf: S L ��p Check No. Check Amount: Cash Amount:
Irlp.,idi. Full 0 Outstanding Balance Due:
=,1
ECTION S: CONSTRUCTION SERVICES
sor(CSL)
I.icense Number Expiration Dale
List C'SL type(see below)
f Descri ion
U 11nm1ricteJ u to 15,000 Cu.Ff.
R Restricted I♦ 7 Famil Mh ellin
signature M M lhll
RC Residential Roulin C'overin
I"depMme MIS R"drnlial Window and Sid
SF Residential Solid Fuel Bumm A fallee Installation
D Residential Demolilion
FRegUterede Improvement Contractor(HIC)r HIC Registrant Name
Registration Number
Espi®tion Date
Telephune
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 2SC(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 ..........O No...........O
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.
Si ure of Owner Dote
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1 as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application arc We and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
75nd,e,.rnder the sins and penalties of 'u
NOTES:
wner who obtains a building permit to Jo his/her own work,or an owner who hires an unregistered contractor
registered in the Home Improvement Contractor(HIC)Program),will rapt have access to the arbiram or guaranty fund under M.G.L.c. IJ2A. Other important information on the HIC Program and
truction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.R3,respectively.
n substantial work is planned,provide the information below:
rs area(Sq.Ft.) (including garage, finished basemenf/auics,decks or porch)
ing area(Sq.Ff.) Habitable room count
f fireplaces Number of bedrooms
f bathrooms Number of half/baths
Type of healing system Number of decks/porches
Type of cooling system Enclosed Open
). "Tutal Project Square Footage"maybe substituted for"Total Project Cost"
CITY OF S.3L.E.M
PUBLIC PROPERTY
DEPARTMENT
[f 1a AL"0adUX L
VArar i 3e v�eaunc7oM 9nFsr Suea�Nwa�oa>srn ON-o
Tor.r..5-7+}9S99 • F.%X 975•740-994
` HOMEOWNER LICENSE EXEIMMON
Pfesse Flint
Dam S , I O. 2 o1�
lob Locstios$r,k52r s "4sla nd man 4(, --p=ece1 es 00I
Home Owner Address
Home Owner Telepbone .moo . 3 cis . "1
Presaot Mailing Address'Po 'fix �6 O M�n�h��r' M A �15'
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 who.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 foam 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 requirements.
HOytEOWNERS SIGNATURE rN
APPROVAL OF SU►WING ►.r PECTOR
See other side for state coda
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTNIENT
'.I „�; L: �C �,I II\� .�•�1C?I:1'r • 1AII M, \L
Construction Debris Disposal ,affidavit
(required lirr all demolition and renovation work)
In accordance t%idt the sixth edition of the State Building Code, 780 CMR section 1 1 1.5
Dcbris, and the provisions of MGL c 40, S 54;
Building Perrnit it is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
l l 1_ S I50A.
The debris will be transported by:
(name of hauler)
'I lie debris will be disposed of in
(na�nr of t'acility)
laddrrs.ul t'acllity) -
signature of permit applicant
$ • lo . 20l c7
date