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9 CLOUTMAN ST - BUILDING PERMIT APP q 2) 1 9LtI iArs The Commonwealth of Massachusetts `t Board of Building Regulations and Standards CITY OF Massachusetts State Building Code,780 CMR SALEM Revised Mar 2011 Cr Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling = -a This Section For Official Use Only Building Pemut Number: ate Applied: Building Official(Print Name) Signature I'yte tf� SECTION 1:SITE INFORMATION - �l,` , 1.01 Property Address: 1.2 Assessors Map&Parcel Numbers u./ t l X l 1.1 a Is this an accepted SJ 1Y AID c�T 1= t'\` street?yes-)- no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 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 OWINERSH1Pa 2.1 Owner'of Record: p, -7 (Yl(C.lfBt�-1 KIFFFHLJ.FJ4 SIMTM c�Cti�C rV� Y�[:s� n 1 1J C) Name(Print City,State,ZIP No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ 1 Number of Units I Other ❑ Specify: Brief Description of Proposed Work : 0 SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials _ 1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee - ❑Total Project Cost'(Item 6)x multiplier _ x 3.Plumbing $ 2. Other Fees: $. - - 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) TOW All Fees:$ h , Check No. Cheek Amount: . Cash Amount: 6.Total Project Cost: $ ©©o ❑Paid in Full ❑Outstanding Balance Due: 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 Unrestricted(Buildings up to 35,000 cu.ft. R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name No.and Street Email address City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(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...........O SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,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 715i OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of pedury that all of the information ntamed in this application is true and cet rate to the best of my knowledge and understanding. rtrii tor- Print Owner's or Authorized Agent's N e(Electronic Signature) Date 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 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.aovloca Information on the Construction Supervisor License can be found at www.nta s.,ov/dns 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" 6,'e o4- Lobr /<, e cic o-cro : �� cx�f c fn l(A C e yl-- U © 19 '?0 Cnll y�)C Of I - S5 ?37 � CITY OF SALEM, MASSAC ME TTS BUILDING DEPARTMENT` 120 WASHNGTONSTREET,3ft0FLOOR TEL. (978)745-9595 FAX(978)740-9846 KIA BERLEYDRISCOLL MAYOR MiOMAS STTIERRE DIRECTOR OFPUBucPROPERTy/BUILDING COMMISSIONER HOMEOWNER LICENSE EXEMPTION PLEASE PRINT. Date 7—/c(—/S— \ Job Location q C-OL)TM-PN �- Home Owner Address v-,r\ '1 Present Mailing Address f cC ✓-y\ V_ 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. Q HOMEOWNER'S SIGNATURE��1 r f\ s1C0 APPROVAL OF BUILDING INSPECTOR QT'Y OF SALEA MA,SSACHUSEM BLUDINGDEPARTARNT 120 WASIM4GMNSTREET,3EDFLOOR TkL(978)745-9595 KIMERLEYDRISODIL FAX(978)740-9846 MAYOR THCMAS ST.PIERBB DIRECTOR OF PLBLicPROPERTY/BumDjNG comoSSIONER Construction Debris Disposa/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, and the provisions of MGL c40, S 54; Building Permit f/ is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste deposit facility as defined by MGL c 111, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in: (name of facility) e (address of facility) Signature of ap licant Date