12 CARPENTER ST - BUILDING INSPECTION ['he Contnnrowealth OI INIasSaChusetts
IIt
BOard Of Building RCgUlatiOnS and S(JrdatdS VI( .Nit"II'.V"I'I )
9u� Saaehucn ss Sluts 13uildutg Code, 78f1 CMR, 7" alitiOit I '.til[
......
[It tld ill e I'etnul tapplicuuon ro CUII SII III[, Repair- Renot ate Or Demolish a hun ,(Jnmttn
One- ar TourFumily [)it rlling 100S
This Section For Official Use Only
Building Permit Number: Date :\pplied: Q�---
si•unature:
9u i Id ug Cum nuns ionCII InspCCwr of Balldl"S Dale _-
SECTION 1: SITE INFORMATION
1.1 Properly Address: 1.2 Assessors :Map S Parcel .Numbers
[.[a Is this:m accepted street? yes— nu \la_ P Number I':uccl ,Numhrr
1.3 Zoning Information: 1.4 Property Dimensions:
7_aning District Proposed Use Lot Area (sq li) Frontage tit)
1.5 Building Setbacks (ft)
j Front Yard Side Yards Real Yard
! Required Provided Required Provided RCquuCd Pnt.idcd
I
1.6 Water Supply: (b1.G.L c 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone:' Municipal ❑ On site dislxtsal spsicm ❑
Public ❑ Private❑ Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownerr of Record:
1 z-
Nuw iuU Address lot Set,ice: --
C�7�i � y��
Signature "relephone
SECTION 3: DESCRIPTION OF PROPOSED WORK' (check all that apply)
New Construction ❑ F_xisting Building ❑ Owner-Occupied ❑ Repairs\s) ❑ rVlteration(s) ❑ Addition ❑
Demolition ❑ Accessoiy Bldg. ❑ 1 Number of Units Other ❑ Specily:
Brief Description of Proposed Work'.
l
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
ham Estimated
and Materials)
I. Building S I. Building Permit Fee: $ Indicate here tee is determined:
❑ Standard City/T'uwn Application Fee
2. Electrical ❑Total Project Coate (Item 6) x multiplier x _
3. 1 lumbing
S ?. Other Fees: $
4. Mechanical (i"IVAC) $ List: ----
5 Mechanical (Fire 5 Total All Fees: ti — -- —
Su) ression)
Check No lheck :lnumnt (•a.h .-Amount:---
ost:
0. Total Project C 5 T� 0 Paid to Full 0 Omalanding Balan,e Due:—
SECTION 5: CONSTRUCI'10`1-1ERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number I?xp)rau on Daw
Naune ul CSL- Mulder
List C'SL l'clie uee hcluwl
Vddws> 'fv sc Deecri own
C finest acted lupin 15,000 Ca Ft i
R Restricted I.@'_ F:mill\ Do%clhne
Signature %I Al asonrs Onh
RC Residentml R oo t pile Cnscrmg
Telephone \1'S ResiJcuuaI \o'i ndw, .ind Srthu_
SF Rr,idenual Solid Pucl Bwou), 1ppli.)nee In.t.ilLmai
D Rr.)denlnd Drinul wn
5.2 Registered home Improvement Contractor IIIIC)
I IC Company Yuma or MC Registrant Name Regutr:won Number
Address —
Fxpiration Date
Signature 'retephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 2506))
Workers Compensation Insurance affidavit roust 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 matters
relative to work authorized by this building permit application.
Signature ol'Owner Date
SECTION 7b: OWNER) OR AUTHORIZED AGENT DECLARATION
1, , aS Owner or Authorized Agent hereby deJd
that the statements and information on the foregoing application are true and accurate, to the best of my knowle
behalf.
Print Name
0
Signature of Owner or Authorized.Agent Dom
(Signed under the pains and penalties of perjury)
NOTES:
I. An Owner who obtains a building permit to du his/her own work or an owner who hires an u111 eI11sicred contracwr
(not registered in the Fiume 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 Lind
Construction Supervisor Licensing (CSL) can be found in 780 CNIR Regulations 110.R6 Lind 110.R5, respectively.
_'- When substantial work is planned, provide the information below:
Total floors area (Sq. Ft.) (including garage, finished basemenVattics. decks nr porch)
Gross living area )Sq. Ft.) Habitahle room count
Number of fireplaces :Number of bedrooms _ --
?lumber of hatthnuuns Number of h:dt/hauhs
l ype of heating system Number of decks/ p,rehcs
hype of cooling system 1=nclused Upen
z 'Total Project Square Footage" may be substituted hot Total Project Cost"
CITY OF SM.EIM
PUBLIC PROPERTY
DEPARTMENT
Kilna:� w rvwvv i
NAVM 130 Wl94NGWM SIRE=•Su.Fx M.SLU34LSEM 01970
TEL 978-74S.9$95 # Fix 976-740-984
HOMEOWNER LICENSE EXEIMMON
Please Print
Date 0
Job Location ( 2—
Home Owner Address
Home Owner Telephone 9 7rc- 7 Ys— - 6 3 70
Present Mailing Address < Xl:�
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 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and remi IAlrements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING ]INSPECTOR
See other side for state code