BAKERS ISLAND - BUILDING INSPECTION (44) f A'�
The Commonwealth of Massachusetts CITY OF
W
Board of Building Regulations and Standa�d�s� RECEIVED SALEM
_ Massachusetts State Building Code, 780 C pECTIONA!_ SE RAt6WJ,6Mar 20L1
Q Building Permit Application To Construct,Repair,Renova e Or Demolish a
One-or Two-Family Dwelling 1015 AUG —1
!(� This Section For Offc' Use Only
Building Permit Number: Dat Applied:
�'o
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Propertysddres / 1.2 Asses�sTo/rs jllap&Parcel Numbers/
NUJ1 'L ll a Its this an accepted strreeett??yes,_ no Map Number 6 Parcel Number
1.3 Zoning Information: 1. Pruppert Dimensio s:
Zoning District Proposed Use Lot Area(sq ft) Frontage(11)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
1.1 Nog'fEe r�'� - G�/"L "n T 1v ,/J'1R o/&'J
Name(Print) City,State,ZIP
/�� /►/ic�ie�s 9?�' ay3 p�{� )gotAAC'carta
No.and Street Telephone r mail Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building M1 Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other Specify: rc
Brief Descr on of Proposed Work :
IF /`Qi l`SS R
/S
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 06 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List: - l
5.Mechanical (Fire $ Total All Fees:$Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 0.aU ❑Paid in Full ❑Outstanding Balance Due:
M�\ L D —t'J �6 13
i
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type - Description.
U I Unrestricted(Buildings up to 35,000 cu.ft..,
R I Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Coverin
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
H
HIC Company Name or HIC Registrant Name IC Registration Number Expiration Date
No.and Street
Email address
Ci /Town,State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFPTDAViT(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 7aa OWNER AUTHORIZATION TO BE COMPLETED WHEN . x
OWNER'S AGENT OR CONTRACTORAPPLIES 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 76!OWNFM 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 est of knowledge and understanding.
/ ej
Print Owner's or Authorized Agent's Name(Ele onicoftnatum) 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 M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass. ov'oca Information on the Construction Supervisor License can be found at wwlv.mass.eov/dos
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 of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost'
e �
CITY OF SALEM, MASSAC ME TTS
sY "sr� BUILDING DEPARTMENT
120 WASHINGTONSTREET,3" FLOoR
\ ,mz TEL. (978)745-9595
FAX(978)740-9846
KIMBERLEY DRISCOLL
MAYOR TrIOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT*
Date v 711 _`
Job Location 3l4k��s �S"��n�
Home Owner Address 132 A&'h-15 Sr ^4 p($87
Present Mailing Address it �r
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 that 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 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 understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
y
APPROVAL OF BUILDING INSPECTOR