7 GRAFTON ST - BUILDING INSPECTION (2) r The Commonwealth of Massachusetts
\\, c ;? Board of Building Regulations and Standards CITY OF
. . ;a SALEM
%. Massachusetts State Building Code, 780 CMR RevisedMv2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
lhisSecfiiarForOffieiaL.flse::... ;:.::::....:.:::::>:::=:::::::
Only
tlQtuiiliers <:<; Rafe 6ti'`
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. :Building O6"idal(Print Nye) ..-- . - -...........Signafire
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1.1 Property rA•`ddress: 12 Assessors Map &Parcel Numbers
C7 Y"A'r TOYS
1.1 a Is this an accepted street.?yes_ no Map Nuttier Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
OR acreS_
Zoning District Proposed Use Lot Area(sq it) Frontage(8)
1.5 Building Setbacks(11)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: O&G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Fl it Zone?
Public* Private❑ — ��� e Municipal On site deposal system ❑
.. _.
3TCTI(31+IZ:.PRORIITIY OWNTRSIIIPk:_' -
2.1 Owners of Record:
'i ran;e.l 'E�1��rda�ri Seler� l Mfl ol��]O
Name(flint) city,State,ZIP
cY18- VaR�LQVI Iolumloe yaboo'cr,
No.and Street Telephone ail Address
........... .
SE4"iTUI�I 3:�? Si P3ION 0F.MOPO.SFJ,D WURIfT(ehedc all wfttapply)
a:
NewConsbuction❑ FxistingBuddin Owner-Occupied •Rcpairs(s) Alteration(s) ❑ Addition ❑
Demolition 0 Accessory Bldg. ❑ Number of UnitsJ_ I Other ❑ Specify:
Brief Description of Proposed Work':
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inl. .t. (-lncl a T•Fwo tJxU
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SE<4MN-*:X$2:04ATEIl CONSTR't7MON CO$'I'S '%-..1.:.
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Estimated Costs:
Item .Otfiefal:Else.Doly::.:<: ..............:
. ... ... ... ... ...
.............:......_....._..,
arbor and Materials ..
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1. Building $ j,pb ild g:PamitFee>5 ` Iriti... stun fe. . det�nined>
2Electrical $ t7taiil:C[ylroin=ltpplicafonFee:::::.:':.:':. :.:::::
OTotaf An(ect Cost(ltean:6).x im tit: is
3. Plumbing $ ::'Quit Fees $:::::.;
4.Mechanical (HVAC) $
5.Mechanical (Fite
Su ssion $ ''Total All roe `:$ 5:':.... . ..;::::..... ...
>CiierkNo).' i.:; iGhgCkAM*01( n=:<:.Z Casi A-moujit-
6. Total Project Cost: $ QC)O , c'U [IPaid:mFu9:.:>:2.:.<.<p.Odtstandirig:BafariceDue:::::.:::.::.:;:i:::::::
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5.1 ConslrucHan Supervisor License(CSL)
Cam— ICA"13
License Nunber Expiration Date
Name of CSL Holder
List CSL Type(see below)
Na and Street Pe::i[ <'::`:: ;:nes.0... .::::::::::<
0'
q U Unrestricted(Buildings to 35 t1o0 cu..&
m �R 1 _ —10 R Restricted 1&2 Family Dwelling
atylfown,State,ZIP M M
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
9-18'8a8•Wt39 �nl �MICse��13�3�xolnoo I I Insulation
Telephone Eo?t ' add:essaddress c o vG D Demolition
52 Registered Home Improvmtad Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or ffiC Registrant Name
No,and Streit Email address
City/Town,City/Town,State,ZIP Telephone
socTloN 6-VVORI{El i C011pENSA'I'I(3i1i INSURANCE AFFIDAV1T:O G3,c_:13L:: 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........... ❑
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.
$ECTION7a::OWNi RAiJIHORIgATION:TO:BE:C WLETED W13EN
_. ..........._. .._......_......_.....__.................. . ... .. ....
OWNERS AGENT OR:CONTRACTOR APPLIES:FOR:BUIIDING PER11difT::>:::::x:F:::<?
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.
Print Owner's Name(Electronic Signature) Date
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......_..._. .,._.._.._..._
STIO1V:1b :OYYNtER1:OR AT7T11QI}I81�tiGh1 E IIECI:ARAlTIO1�I::
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOIE3 ::
1. An Owner who obtains a building permit to do hishmer own work,or an owner who hires an unregistered contractor
(not registered in the Hone Improvement Contractor(HIC)Program),will tit have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be food at
�acclv,mass.eov.oca Information on the Construction Supervisor License can be found ataw3j ma e.gov/dos
2 When substantial work is planned,provide the information below:
Total floor area(sq.R) (including garage,finished basementlattics,decks or parch)
Gross living area(sq.R) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number ofhalf/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!'
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CITY OF SM-0oI
PUBLIC PROPERTY
DEPARTMENT
Vwroe 13M0089Ic JIMAM•WAK MAMAOras<r11019V
ra ./'&745•9s"•V.%&975-746964
HOMEOWNER LICLNSE EXE.I� MOM
PkaM Friatt
Dan 1 ��
Job Locadow —1 H rG e(\
HamOwnerAddtear —I C ea4un —
Home Owwr Telephslae G-7'k - 42 a'2 —L18 3-
Presad Mailing Address merit 4
The cusmat exemption of 6 Homeowners"was extended to include owrnw-occupied
dwellings of two Units or lea and to allow ouch homeowners to engsgs an individual for
hire who dodo not possess a Ifeans%provided that the owner act@ as supervisor.
DEFINITION OF HOMEOWNER
Petson(s) who owns a parcel of land on which he/she redden or intends to reside;on
which then is, or is intended to bs6 a one or two family dwelling, attached or detached
structures accessory to such use and/or farm structures. A person who construct@ more
than one home in a two year period shall not be considered a homeowner. Such
,,homeowner"shall submit to the Building OQleiai,on a form acceptable to the Building
OfiiciaL that he/she be responsible for all such work performed under the Building
Permit
The undersigned "homeownea"assume@ responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner'certifte@ that he/she undentands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
Mill comply with said procedures and requirem LL
HOMEOWNERS SIGNAMM
APPROVAL OF SUILDENG WpEcr
See other side far state code