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8 BECKET ST - BUILDING INSPECTION The Conuronwe:dth of Massachusetts Board of Building Regulations and Standards CITY OF 'r w, Massachusetts State Building Code, 730 CNIR SALL\I Building Permit Application TO Construct, Repair. Renovate Or Demolish a One-or Two.Fmnilr Duelling This Section For 011icial Use Onl Building Permit Number: Date Ap�d• , _N/L1[ltMLl. Lurr7 ws o 7 Mudding 011icial(Print Name) , i ur Dale SECTION I:SITE INF RMATION L I Pro terty AJdress: 1.2 Assessors Map & Parcel No e 8 l��.l.> 1 s� SGIYr /v\A I.la Is this an accepted streetl yes no Map Number reel her 1.3 Zoning Information: 1.4 Property Dimensions: 19 Zoning District Proposed Use Lol Area IN It) F mage(II) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:( G.I.c.a0,§5a) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public Private❑ Zone: _ Outside Flood Zone? Check ifes❑ Municipal�On site disposal system ❑ SECTION2: PROPERTY OWNERSHIP' 2.1 Owner$of RecordL_ N;une(Prim) 1 ) S—Jives 1A, D l a o city.state,ZIP :Er cre4 , 342-Qoa- taa� l ,y.vv l� :rlca 1 No.and Street Tele hone —� 1` °' o vvv P hmad Addms SECTION 3: DESCRIPTION OF PROPO D WORKr(check 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-: a, o _ 01 �t ti SECTION a: ES MATED CONSTRUCTION COSTSdV Item Estimated Costs: Labor and \laterials) Official Use Only I. Building S I. Building Permit Fee: S Indicate how fee is determined: 2. Electrical S ❑Standard CitytTown Application Fee i. I'lunthing S ❑Total Project Cost'(Item 6)x multiplier x ._-_-_-- _. Other Fees: S 4. \lech:mical illy:\('1 S Lisc I i. .\Ic: III Fire --- ------ l Su t S rural :\II Fees: S_ --__ ------ -'-----_ . n. Total Project Cost: S Check No. __—Check amount: - -------C•,tsh :\inount: < ❑Paid in Full ❑Outstanding Bal:mce Doc: T�/k/T f� SECTION 5: C'ON51-RUCTION SERVICES 5.1 Construction Supervisor License(C'SL) License Number P\pinniou Dale N11111e of l'SI. I odder List('St.1)Pl'(see below) "f.%PC Description N". Mid Street I l nrestricted I Ihli ldin n up to 35,000 cu. It _ R Restricted M2 Fumil Y Dwdlin l'ilci l'ols n. Some.LlP M Masmiry RC Rlwth C'uvcrin WS Window and Siding SF .Solid Fucl llurning Appliances I Institution I'cic hone Ismail address D Demolition 5.2 Registered Home Improvement Contractor(HIC) IIIC Registration Number ISspimuion Dine I IIC Compan> Name or I IIC Itegistrunl Nan1c No. and Sl cel Emuil address City/Town,State,ZIP Tale hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject property,hereby authorize to act on my behalf,in all platters relative to work authorized by this building permit application. Print Owner's Nune(Elecuonic Signature) Date SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information comame n this application is true and accu a to the best of my knowledge and understanding. tint Owner's I,:\uthohicd.\gene's Nnn1 11cctrunlc Signature) atc NOTES: I. 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 no 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 m.r.. �;o1 ,'r,l Information on the Construction Supervisor License can be found at mas+ Ip. \\'lien substantial work is planned,pro\ide the information below: Total floor area(sq. ft.) _ (including garage, finished basement'attics.decks or porch) Gross tieing area(sq. fl.) _. ---- " _ Habitable room count Number of fireplaces._-- Number of bedrooms Number of bathrooms Number of half h;nhs I pe of heating s>sicnl _ .. _ . _ _ Number ul'decks, porches _ I\Ile ill 6101i116 s\Aelll - Enclosed (1pe11 i 1. "1*oral Project Square Footage"maq be substituted for"Total Project Cost- yi CITY OF SAI..E.bt PUBLIC PROPERTY DEPARTMENT u.aut AV 04MAXi .,"VM 1]e WM*WSMa must/•s uaK w:uoRs■rn or+-o ML 9-1-745•75t!•v.%L 1'L7�6'7ay HOMEOWNER LICLNS6 EXE.MMON Pkw Ftrlet � , Job Location az VY4 Ss /,A Q cz, o Home Owner Address 4s v,� s �vt A o L of 1 o Home Owner Telephone � - � e a - t Clci Preamt Mailing Address s S t a-1 The current exemption of"Homeowners"was extended to include owner-occupied dwellings of two Units or teas and to allow/such homeowners to engage an individual for hire who.does not possess a lieu provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(a)who owns a paced of land on which halshe 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 Omcial,on a form acceptable to rho Building OtHciaL that he/she be responsible for all such wort performed under the Building Permit The undersigned"homeowner assumes responsibility for compliance with the State Building Code and other applicable by6laws 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 SIGNATLRE � ,:/ ed v/ APPROVAL OF BUILDING INSPECTOR See other side for state code CITY OF S,V-ENf, ► kss.1CHL'SETTS ©LLMLVG 0EP.1ATtE,`T 120 W.umLYGTON STAE$T, j 4 FtOCIt rM (978) 145-9595 K1J®ERF AY DVWOLL FAX(978) 740.9846 MAYOR niO-mU ST.P[PA 0I1EGT04OP PLBLIC PKOPEItTV/B(.:QDOJG COJp1tSSIONEX Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition orthe State Building Code, 780 CUR section 1 Debris, and the provisions of MCL a 40, S 34; Building Permit M is issued with the condition that the debris resulting from this work shed be disposed of in a pro en 11 I, S I SOA. perly licensed waste disposal facility as defined by hICL c The debris will be transported by: Iscllu tJGs�� of hauler) The debris will bo disposed of in : (name or'fanlity) Oddreu or fjc,I,ly) namre of permit I PPiu f •pry • I� .'y'