LOT 71 BAKERS ISLAND - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 730 CMR SALEM
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised,tkir?01i
One-or Two-Frrrnify Diveiling
Building Permit Number. This Section For Official Use Only
Date;App 'ed:�
building Official(Print Name) '�� ' _ ��
ignature,✓ Date
1. SECTION I SITE INFORiMIAT10N
- 1 Pr ert Address: -
1.2 Assessors Map&Parcel Numbers
I.1 a is this an accepted street?yes_ no Map Number ,.
— 1 urcel Number
1.3 Zoninglnfa:matimt:
1.4 Property Dimensions:
Tuning District Proosed Ua—p e
Lot Area(sy ft) Frontage(It)IS BuildingSetbncks(ft)
Front Yard Side Yards ProvidedRe
Require) Provided Rear Yard
Required aired
y Provided
1.6 Water Supply:(M.G.L a 40,§54) 1.7 Flood Zone Information:
Public❑ Private❑ Zone: _ Outside Flood Zone? 1.8 Sewage Disposal System:
Check if es❑ Municipal❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Owners of R cord:
1' �
r„e(Print
QPi S
� � 1 ,� 2 . � City,State,ZIP
r
S
Tel hone Email Address
ECTION 3: DESCRIPTION OF PROPOSED WORK (check all that, l v�rY
New Construction❑ Existing Building Cl Owner-Occupied ❑ Re airs s ❑ Alterations) 0 Demolition p O O Addition ❑
❑ Accessory Bldg. ❑ Number of Units
Brief Description ofProposellWork% Other ❑ Specify:
U p
L9 (7 I
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials) Official Use Only
1. Building S I. Building Permit Fee:S Indicate how fee is determined:
3. ElectricalS ❑Standard City/Town Application Fee
3. Plumbing $ ❑Total Project Cost"(Item 6)x multiplier x
?. Other Fees: .$
4. kfecilanical (I-IVAC) S List: 1 ��
.i. �\iechanird (Fire _ l
Suppression) '$ Total All Fees:S
6. Total Project Cost: .s /�—Q 0 Check No._C'heck Amount:
Cash Amount
❑Paid in Full ❑Outstmtding Oalance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Cunstructimr Supervisor License(CSL)
---- Expiration Date
License Number p
List CSL e I
Name of CSL Holder 'rypsee below)
De
( ti
scription
Type
No.and Street U Unrestri etc d Buildin s u to 35.000 cu. I1J f
It Restricted 1&2 Family Dwetlin
M Mason
Cityfrown,State,ZIP IiC Rootin Covering
WS Window and Sidin
SF Solid Fuel Burning Appliances
I Insulation
.— Email address D Demolition
rc none _
5.2 Registered home Improvement Contractor(HIC) HIC Registration Expiration
IIIC Company Name or HIC Registrant Name
Email address
No.and Street
Telephone
Cit /Town,State ZIP
RS'.COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.¢ 25C(
SECTION 6:WORKE ..
Workers Compensation Insurance affidavit must be completed and sub
with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building p
Signed Affidavit Attached? Yes ..........❑
No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN:
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PE
RIVIIT
1,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Date
Print Owner's Name(Electronic Signature)
ON
SECTION 7—OWNERt ORAUTNORIZED AGENT DECLARATI
13Y 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 best of my knowledge and understanding. 2 D '
�piU A 1 T] 0 YZ Date
Print Owner's or Authurized Agent's Name(Electronic Signauire)
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or antownertl l`ha e hires
ac access totthe arbitrationcontractor
(not registered in the Home Improvement Contractor(IIIC) Program),
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program can be found at
www.mass.^oaranainformation on the Construction Supervisor License can be found at w'ww.mass."oyv.dL
2. When substantial work is planned,provide the information inglgarage, finished basemenUattics,decks or porch)
Total floor area(sq. ft.) Habitable room count
Gross living area(sq. 8.) Number of bedrooms
Number of fireplaces Number ofhalf/baths
Number of bathrooms Number of decks/porches
Type of heating system Enclosed�— Open
Type of cooling system
bstiuitcd for ToCd Project Cost"
} "Total Project Square Footage"may be su `"
CITY OF S.Cuz t, NLASSACHUSETI S
i" BUILDNIG DEPAM- &NT
130 W.ISHCYGTON STREET, 3T FLOOR
TEL (978) 745-9595
KIJCBERLEY DRISCOLL F.ix(978) 740-9846
N AYOR THObNs ST.PmRRa
DIRECTOR OF PUBLIC PROPERTY/StMI)IING COSOIISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, mid the provisions of tbIGL c 40, S 54;
Building Permit k 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 tMGL c
l 11, S 150A.
The debris will be transported by:
y (
(name orhauler)
The debris will be disposed of in :
(name of facility)
�C;7or,- e
(address or facility)
signature of permit applicant
'late
CITY OF SALEM, MASSACHUSETTS
BUILDING DEPAR-ImENT
120WASFUNGTON STREET,3m FLOOR
r TEL. (978) 745-9595
FAX(978) 740-9846
KIMBERLEY D]tISCOLL
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONWSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date
Job Location /,S i3�Q�^$ 1/S aVl4 // I
Home Owner Addressj g;,-Ac l� I �,r� a ax,� c r �4 l`� 75'
Present Mailing Address
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. 1
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 1 )C YL in
APPROVAL OF BUILDING INSPECTOR
...........
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