16 GOODELL ST - BUILDING INSPECTION (2) s �
The Commonwealth of Massachusetts
pp Board of Building Regulations and Standards CITY
g m OF SALEM
Massachusetts State Building Code, 780 CMR, 7 edition
Revised Junmvv
n� Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 'oUY
r I One-or Two-Family 9411ing
ffhi Section Fo54fflcial Use On
Building Permit Number: Date Applied: v , t V
i
Signature:
Building ommissioned In o fBuildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Ass esao Map& Parcel Numbers
/f, kopd eil Sf, �' Zoo- 9
I.1 a Is this an accepted street?yes_✓ no Map Number Parcel Number j7, 6091 0
1.3 Zoniug�!,ormatlon: 1.4 Property Dimensions:
)2e�ricn � l No:xe- ` .QI s1, •Ft 5I0 -F+
Zoning District proposed Use Lot Area(sq R) Frontage(tt)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Private❑ Zone: _ Outside Flood Zone?
Check if esQ," Municipal U'On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
5+evEn E. rooes
Name(Print) Address for Service:
"'1Z r g -79-- . . V
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Building Owner-Occupied- Repairs(s) Alteration(s) ❑ Addition ❑
Demolition Cl Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': m a i a .!
Rot,/`
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 0fllcial Use On
Labor and Materials Only
I. Building S A 5L�o ,d e; I. Building Permit Fee:S Indicate how fee is determined:
�. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2.Li Other Fees: S /1/ � �
4. Mechanical (HVAC) S List:_ n
5. Mechanical (Fire S
Suppression) Total All Fees:$ -
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S ❑Paid in Full ❑Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name ol'CSL-I lulder List C'SL Type(see below)
f.PC Description
Address om .000 Co.Ft.
FR R R aJ Dwelling
Signature M Mason Onl
RC Residential Roolin Coverin
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
IIIC Company Name or IIIC Registrant Name Registration Number
Address Expiration Date
Signature Telephone
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...........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.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
II i-
I ✓t 0 2,—5 ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf. �
J uei� E. J 0425
Print Name it y_�o_,6
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of 'u
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 agol have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I IO.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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 l
en
Type of cooling system Enclosed_Open
J. -Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF S.ULE.M
PUBLIC PROPERTY
DEPAM. iENT
TrL vs-745-0s"9 FtAr 978.740.9L4
HOMEOWNER LICENSE EXE..NMION
Plena hint
Date N --ZO —aO
Job Location
Home Owner Address
Home Owner Telepbone 9-1k -yXq-.1./ 74
Proud Mailing Address /G 6aede{/ Si-: S'Q/rrc M
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or lea and to allow such homeowners to engage an individual for
him who.does not possess a license,provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Persoo(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 Salon
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNAMM
APPROVAL OF BUILDNG INSPECTOR
See other side for state code
�\ CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
I •I"M I:C`�.1 N 11\I.. lV)1 Mkr i •).111\I.fit.\��\I 111 J I
.•.1't .
Construction Debris Disposal Affidavit
(rt yuired I'ur all demolition and m-novatiun work)
In accordance with the sixth edition of the State Building Code, 790 CMR scetion 111.5
Debris,and the provisions of MGL c 40,S 54;
Building I'errnit N is issued with the condition that the debris resulting from
this work shall he disposed of in properly licensed waste disposal facility as defined by MGL c
t 11. S t 50A.
The debris will be transported by:
plume ul'hauler)
' 'he debris will be disposed of in :
S �SQI4,V\
(nameul a�Qlll�
SfpIRM SC�'7/ FQ �ejeot 9#4
aJJreall ut'I'x dilyl
.IItnature of mmit appti¢an1
110
date
Id•u..0 .. i