BAKERS ISLAND - BUILDING INSPECTION The CammotInkiWealth of Mussuchusptts
Board_of Stulding Regulations and Suindurds I OR
c� i� ' Mussuchusetts State Hutldmg Code 78U CMR.T"edition MUNtC IPr\I I I l'
v �1 % USE
Butldmg Permu Application To'Construct Reparr Renovate Or;Demoltsh_u RC1,11XV JrYmt, Yo
` '` ' One or.7ltro-Friinilv.Dx'etling-" ;. 1, �rNhY ,
C,�, ? ? ,' Thts Seu&m Foe Offict¢I Use Onl
ilueldmg Permit Nam Date AppLed `i*J, Cr U
} Signatures' O
• ' < , Bu„iWingCammtssioncrtlnspectorotBulh!logs "`; Dute .. , • ,. ", _:' " "•
SECTION.I rS1TE:'.INFORMATION, .• ' ,
is P -Addy Ic2 Assessors Map dr Parcet Numbers
,
Is u Is this un auepteds[trxtt yes ` an Mftp Number: Purccl Nutninrp ,
L3 Zoning Informatlon 14 Pro etig,Dl ettsions
� r
•Zoning District.t ; Proposed Use" L.nt Aren( 'RI; ' Frontage t h
,•�-Front Yard ,i, Side Yards :4 ;. ,•Rear Yard •
.'. Reyulred�?- •" Powded 'Required Provttied `Regwred`- � ,Provided
f Water Stipp(y (M.O.L c 4a §54) 17 Flood Zone Information 18 Sewage Disposal System
Zone `Outside Flood Zone4 -
PublicO ":Pnvate C) CiiecFrtPyes❑ . Munictpnl•❑;Ott site dtsposnl system ❑
.,,
SECTION2. PA DPERTYOWNARSfIw
2;: Ownert of Record.
Ngma(Pent) - Address for Serwte t `
SIBnature — , .T ctF
noneTM'
SEGT►0N,3s DESCRIPTION OF PROPOSED WORK=(check aU that apply) ,
New Construction❑ EXsnng,8uikling O Ownm Occttpied ,❑ Repatrs(s) . ,Alteruoon(s) "❑ ,Addtnna ❑:,.
Derrtohtion ❑ Accessory$Idg O Numbtxof[Intts Odter ❑ Speury e'
Brief iTescd don of Pro ad Wark3
,. . ,
•SECTIpN 4;ESTRKATED',CONSTRUCTION COSTS,
Estimated Costat + ':
Item O/BtSa!LTse Only
and Materials)
L.$uNding ' s S t Butid)ng Permit Fee $ fndic¢te fiuw fee is determined:: .
2,°Electncal, 'r $ t7 Sttutdard Ctrylfown Application Fee
❑ )oml Protect Costs(Ifem 6)x mulnpber ` s
. " 3.`:Plumbtng
4:Mechnnrcal
5:Mechanical f(Ftre $
Su resswn)• TOu!All,Fees`S
6 TotalCheck N4 Chet.k Amount. T_Cash Amotuit.
❑Patti in Full . "• ❑Outstanding Bulaaee Due.
t: � ,
A
y
P4,
i ` ` ' 'SECTION 5 CONSTRUCTION SERVICE$ ; s};. ,51 LlCeosed Construct bb SuperiLsor'(CSL)
EnP# lion Date : '
s xWstCSLTYPetseeFxktw)
'- 4dtln.-t � „ ry ' rtal S Dbt1 Cu Ft E.. ;
gn e hdrietdn�Pmil Duel link
Si '>
Mason ;Onl s .
7 RC ! Rtzidenftsl Raofin Cdvenn
-: Tciephane'. . W5s Residcntiol WintloiJ.tiirl Sidui :
'� �,I �. ���' ?�,, �� SF ;. R�sidenlial SuIW Fuil Bumm A h.uuw hiatali.iixin
,t , ,. •:z-.; . . D +,: : �Resideni(ab;Demuhiwn,,
� 5 a ted o �� Emprove" n ntractor tHIC) A '
HIC Copgiany Noiis HIC Itconmt Name :RegistMmn Nu r
Address )"
Es rndoa'.
Signature Telephone':
58CTION 6s VYORKERS;COMPENSATION hYSURAN@E AFFIDAVIT{M G L c 1S2 $25C{6))
Workers Compensation Insurance affGtnvn ma`s[be compiefeti and submitted with this application. Failure to pntvde
this affidabtt will result in the denial of the[nsuance of the tiuitdm ermu
SigiudePffidavtl'Attached? Yes 0 Nb E .pIJ
SECTIONi7i OWNER AUTHORIZATION TO BE COMPLETED WREN
OVi7VEIt S�A`GENT:OR CONTRACTOR APPf IES FOR BUII DING'PERMIT
of the subject prdpeity hereby
ink act on my behalf.,to ill matters
relative tbiwork authoared by thus building permit epplkation , ' `
'Si turrof owner . ' �Dote• „ -r— �—
SECTIONJIi OWNER1 OR AUTHORIZED AGENT;DECLARATION
!1
Authorized Agent hereby declare"
that the sWile ments amI mfortimtnin on rite foregoing apphwUon arc hire oml accurate.[o the tiest of my tciiowledge and
behalf.
Signature eE owner or Aothorhxd Agem r Dote
Si edua0err`the " ncaad naitlea'.-oF ..'
r F
.
t An Orvhier who oiitmns a building permit to do histhl b44 pr an owner who hues an unregistered cantructnr
(not,regiatered is file Aame IiiprovementContraclor,(FAC)Program) wi11 have'd¢Ce§s to the ariitratutn
program or gtmrrerity fund 6ntlrM O L e' I42A Otlr*f mpottant information on the HIC Program 5nd
Construction Supu,,vuEor Lkeaupg(C5L�can 6e Pound.io�780 CMR Regulauons I IO R6�and I IO RS;re5pecnveI
r' Whensubsmntiel work is to ed provide We infarmatioa belotw' ;
kTotal floor`s urea(Sq Ft.) - uieludI garage.fimshetl basemehihitie desk ur ptmh)<�
Orpss living area tSq FL) Y Hobhable room�oua[
`Number offireplaces � Ntimber of liedrooms ' '"�
Number,of bathrooms Number of tin{f/baths
Type of heating system Numbu of detksl pun ties
?Type of iophng system Eta losed Ope
3 7otal�`Proleet Sytare Foomge''may be substituted for_"'!'mal Project Cast _
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CITY OF SALEM
PUBLIC: PROPRERTY
DEPAIZ'I'�IENT
III '1;. �;a; ♦ I \V 'i-.Y.•J: 1i4,.
Construction Debris Disposal .-affidavit
(rcquired lbr all demolition and renovation work)
In accurdance %%ith the sixth edition of the State Building Code, 780 CNIR section I I L5
Debris, and the provisions of MGL c 40, S 54;
Building Permit t is issued with the condition that the debris resulting front
this work shall he disposed of in a pruperly licensed waste disposal lacility as defined by MGL c
I 11, S 150A.
The debris will he transported by:
(name of hauler)
Ilie j debris will be disposed of in
Sam�
2 (nameu(I'ntity)
Uuldrci< ul lacilil V)
X,r//(,
�Ignatwc >f pannit ,y\plicat
D
Date
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