9 CONNERS RD - BUILDING PERMIT APP --- I'IIc COm11,01,weallhof M1'I:usacluuclts
Board Of Building Regulations vld Standards CITY OF
M1fassachwctrs State Building Cute, 7SO CNIR �.1LIi•\I
Building Pennk Applic Tian TO Construct. Repair, Renovate Or Denndish a
one-or Two-f2unih fhrdllinp
Building Permit Number: This Section For O •ial Use Onl
ate Applied: )
IhiilJing Uliicial(Print Nmne) 410d ,�
signalu Bale
I.I P SECTION I:SITE INFORMATION
r erty Address:n z,r¢ & —� 1.2 Assessors slap& Parcel Numbers
I.l a Is this an ncs a ted street) •es no o 6Lip Numhcr
1.,1 ZonlnE infonnatlom I urcel Number
1.4 Property Dimensions.
Zoning District 11—��—
Lut Arcu(sy III Pronmga(11)
1,1 Building Setbacks(R)
Front Yard Site YardsReyuin:d Provided Required Provided Near Yard
Required Provided
1.6 Water Supply:(M.G.I.c.40.§») 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private O Zone: _ Outside Flood Zone?
Chock it es❑ Municipal❑ On site disposals)stem ❑
SECTION I. PROPERTY OWNERSHIP'
2."wnerlo Resrd:
N;mw +rim
/1 /1_ c
/ (uy Slulc.11P
Nu..mJ Stul
Telephone Elnuil Address
SECTION it. DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied 03 Repairs(s) ❑ Alteration(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units
Brief Desc illation f Propos Work': Other ❑ Specily
SECTION a: ESTIMATED CON51FRUCTION COSTS
Item Eslimated Costs:
I L abur and.\l:uerials) Official Use Only
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
'. I:'Icctrical S ❑Standard Cilyr7'o+sn Application Fee
1. 1'lumhing S ❑Total Project Cost'(Item 6)x multiplier
2. Other Fees: —
J, .\Itch.lnic.11 ill\.10 S List:
�. \lech.Illical tFire ---
\u,vessiunl S rotal .\11 Fces: S_
Total Prnject Cost: S C11"k No. _('heck:\nnnum:
C,uh \nunnn:
0 Pnid in Full O(AtlsumJing B.Il:mce Due:
---------� sF.(JI0N 5: CONS I'RIICTIO1N�SFRVI(
('onstructiol' Sul)cnisori,icelist((St
t,piniiion I)aIc
Name of CSI. tQr
j it it)35.000 ol.
Famil) I)Nwllill
R tri I
L MIT,M11.Sti"- RC
WS Window aid Sidinla
IF Solid I:ucl Iluming Appliances
I Insulation
Email Atimss I)
Drnlolilian
141c hone tit Contractor(HIC)
41.2 Registered ilume Improvenal IIIC Ilegijr,11un Ntunhr 1:,11iration W19
I IIC Ck),np,u,) Njune or I IIC licilustrunt Name ------
�1 mail address
No.mid Sued
Ci fl*own State.ZIP rele hone 152.1 ZSC(6))
WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L C,
r"_"AFFIDAVIT
'' % _Failure to provide SECTION 6:WORKERS' U 'n with this at,011- 0 provide
wi is application. Failure t
Workers Compensation Insurance affidavit must be completed and submitted-ed with th
this affidavit will result in the denial of the issuance or the building permit
Signed Affidavit Attached? yes ..........13 No...... ....13 HEN
-�_ .-_'i,—.vr 1 F_rF 0 8 E COMPLETED W
ATI'6
SEC
TION-5j:OWNER AUTHORIZATION
OWNER'S AGENT OR CONTRAC
TOR 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.
-----�Dote
Flni—AU,,,er's Nunic(Electronic Signature) ------
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below-I hereby attest under the pains and penalties or perjury that all of the information
contained i 's application is true and accurate to the best or my knowledge and understanding.
Date
Print t %%ner i or Authoril 11,4 Name( Iccutinic Sign;14
NOTES:(.\nno t0 reg 7i;sre%r ehdo inobhtaeli HTs uabeu iI mipnrgo peemrmenit t tCoonot hcst ohre r(Ho wICn) Program In i
rogram)nw o%l
vl nae)r shave access
n t-uo-n-tr-he-
eg iasribcirter
d tciounn ir- or
on the HIC Program can be found at
program or guarant) Fund under 14I.A.other inipuriont ormation
lnra rnj�ition on the Construction Supervisor License 0n be round at
en substantial\cork is planned, pro%ide the infuriation below:
I including garage, finished bascinent attics,decks or pordil
total t1our area IN'+ Habitable room Count
G;rossIi%i,19Mea('4 Nt,111her ofbedroonis
I of fircliiklccs ... \L11iibvr ofliall'Kill's
Ntimher tit hathW011's Ntiniticr of decks, lhirdIvs
F )f 1w.ttilig i1ilClll 1�iwlosed
F\re A Cooling i1 Sion 1113\ be'"hstitutcd i1ir 1*001 Project COst"
Project skltorc Foo,,We
v
CITY OF S.U-E.tit
PUBLIC PROPERTY
DEPARTt LENT
1U.o.aur CMUSU"
V'"'Oe t b sww,-7oM StrWr•l�ua4 V�a�owsrrn Ot•'0
ru.rs-145.91" •Y.%L 07e.749e46
HOMEOWNER LICUSB EXE.MMON
Plan" "I
D. 5,-IZ / z /�,�p
Job Loeados 2 L /-'IV c�.l=-R k-.100e g
Home Owner Addr as <::;: A " v
Home Owner Telephone
Present Mauling Adduces
The current exemption of"Homeownere was extended to include ownaroeeupied
dwellings o[two Unity our less Wild to allow such homeowners to eagags ao individual for
hire who.does not possess a Ileeose,provided that the owner acts n supervises
DP.FIMMON OF HOMEOWNER
Persons) who owns a POW Q(WW on which holshe rtaidee or intends to reside,on
ie which that , or is intended to be,a ova or two rJudly dwelling attached or detached
Structures accessory to.such uses and/or rum Structures. A person who consa uts 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 hdsho be responsible for all such work performed under the Building
Pamit
The undersigned "homeowner'uJIU fa responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner^certifies that Wsho understands the City of Salem
Building Department minimum inspection procedures and requirements and that helshe
will comply with Said procedures and requirements
HO.IEOWNERS SIGNATL �A ��
kPPROVAL OF SUILDING NSPECTOR
See other Side for stale coda