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BAKERS ISLAND - BUILDING INSPECTION (41) fhe Commonwealth of Massachusetts IBoard of Building Regulations and Standards CITY / Massachusetts State Building Code, 780 CMR, 7'"edition OF SALEM Revised Juntrnrr• Building Permit Application To Construct, Repair. Reno�rte Or Demolish a /. 2/x6Y One-or Two-Family Dwelling This Section F r Official Use On Building Permit Number /^'�' ate A plied• / Signature: h/ �iy ` /0 Building Commilisionert Inspetatir of Buildings Date SECTION 1:SI E NFORMATION 1.1 Property Address 1 Al Mrs Map A Parcel Numbers . ulna) ° l� ogr.3 1.la Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: TR_r ton nC) Zoning District Proposed Use Lot Area(sq 11) Frontage(11) 1.5 Building Setbacks(It) 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 Informallon: 1.8 Sewage Disposal:System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if es❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: 'l7ou cic�C t.l .�ti�rsza1 � 'i�f� ax38� M-m ckes�r'- MA 0)9 `d `} 11 Address for Service: t/ �� 57iC�C S o lg- • Signature c Telephone SECTION J: DESCRIPTION OF PROPOSED WORK'(chock all that apply) New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work': SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building S p Vp — 1. Building Permit Fee:s Indicate how fee is determined: 2. Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x J. Plumbing S 2. Other Fees: S 4. Mechanical (HVAC) s List: S. Mechanical (Fire s Suppression) Total All Fees:s Check No. Check Amount: Cash Amount: 6. Total Project Cost: S 2�vo, •— 13 Paid in Full 0 Outstanding Balance Due: SECTIONS: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) ACSL ber I:Nplratlan Irate Name ol'CSI.• I IuWer pe(are below) Descri ion Wdress amoicted u to)S000Cu.Ft.estricted 132 Famil UwellinSignature Only RC Residential Roulin C'overin telephone We, I Residential Window and Siding SF I Residential Solid Fuel Buming Appliance Installation D I Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) I II(:Company Name or FIIC Registrant Name Rcgistrwion Number Address Expiration Date Signature 'relephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.f 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 ..........❑ No...........O SECTION 72: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. siumurc of Owner Date SECTION 7b:OWNERt OR AUTHORIZED AGENT DECLARATION F-W ,as Owner or Authorized Agent hereby declare statements and information on the foregoing application are We and accurate,to the best of my knowledge and me Signature of Owner or Authorized Agent Date Si undf1heams and nalties of 'uNOTES: I. An Owbtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not re the Home improvement Contractor(HIC)Program), will gd have access to the arbitration progranty fund under M.G.L.c. IJ2A.Other important information on the HIC Progrem and Constrervisor Licensing(CSL)can be found in 780 CMR Regulations I l0.R6 and 110,RS, respectively. 2. When substantial work is planned,provide the information below: Total floors 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 of healing system Number of decks/porches Type of cooling system Enclosed _ Open ). "Total Project Square Footage"maybe substituted for"Total Project Cost" CITY OF SUE-Ni PUBLIC PROPERTY DEPARTMENT NAvo0 13e WASUNGWW SMIFT•y.•K HAssACMAC R 019.0 Tm 9'6-745-9sss• V%x 9'6.74a964 HOMEOWNER LICENSE EXEMff1ON Plow "I Day g, 12. 20 10 Job Location �Q Ice ss M¢ I a n e- Home Owner Address jFCl B vx 3 S o m e,.c InoSje r m A Q i o i 4 1 - Home Owner Telephone -So B. as-s- s Z 7*i Present Mailing Address -P© :a-w also r1w.uwa..1 rrt A ot944 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. 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 subunit 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 y 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. HOMEOWNERS SIGNATURE "l/ APPROVAL OF BUILDING INSPECTOR See other side for state code CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT \I`.t,9t 120 W.tiI Irm;tON 5rN GET ♦ SA 1\1, MAiiACI It it.I ii frl t 9"8-N 9i95 ♦ 1:AX:978.74}')846 Construction Debris Disposal Affidavit (required fur 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 # _ is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c t 11. S 150A. The debris will be transported by: iname of hauler) The debris will be disposed of in (n:une of faci ity) (address of facility) signature of permit applicant date dcly uatr dew