12 HAYES RD - BUILDING INSPECTION (2) f
V�/ - --- ----- I'he Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code. 780 C'MR SALLM
'L.,.. le ur_'llll
Building Permit Application 'ro Construct, Repair, Renovate Or Demolish a
One-or Two-Furni/t' Dn ellhnq
This Section For icial Use Only
Building Permit Number. �Date Appli•d:
Mudding 011icial(Print Nmne) Signature Da1e
SECTION 1: SITE INFORMATION
1.1 Proper" Address: �/�S LZ Assessors Map St Parcel Numbers
20� D
1.1a Is this an accepted street?yes no Map Numixr Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Usc Lot Area(sq 11) Frmnoge 00
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?Cec es❑ On site dispos"al s -stcm ❑
SECTION 2: PROPERTY OWNERSHIP"
2.1 Owner"of Record:
Nan,c(Pun") uty.Stale,ZIP -
Nu. anJ,"net y ` V_ �"�—
Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ E.risting Building❑ Owner•Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ I Other ❑ Spccit'y:
Brief Description of Proposed Work':
i�r�7- 12 10 A—/,!�7 Y . �
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item - Estimated Costs:
(Labor and \laterials) OfOcial Use Only
I. Building S 60 I. Building Permit Fee: E Indicate how fee is determined:
2. Electrical g ❑Standard City/Town Application Fee
7 Plumbing Loa ❑Total Project Cost'(Item 6)s multiplier
� O 2. Other Fees: S
j , S — -------
4. Mechanical (MAC) S Lisl:
I ;. ,\lechanical I Firc --_ ------ ----- --
jSu„ression) S Toad :\II Fcc$: S_ --__ - —.----- ------- .
n. Total Project Cost: S q Check No. _ _Check Amount: _ C,tsh :\m�iunt:
v I aL) , L (J ❑Paid in Full ❑Outstanding BuLmce Doc:
i
t
SECTIONS: CONS I'RUCrIONSERVICES
5.1 Construction Supervisor License(CSL)
License Number---- --- F\piraliou Dane
Nallcot'CSL llolter --
List C'SI.I)ps:Isee hclow9 -
---------- t. pe Description
No. and Street ll I Inrestricted I Ouildin k's up to 15,000 eu. 111
It Restricted 1,2 Famil Dwellin t
Cit�i fort n,.tinne.ZIP ---_—.... - NI Nlasollry
RC Rtwlin C'u\nrin
R'S Window and Siding
SF Solid Fuel Ruining Appliances
I Insulation
I cle hone Finail address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
IIIC Registration Numltcr li.\pirstion Uatc
IIIC C'ompan) Name or IIIC Regislrunt Name.
No. and Sueet Email address
City/Town,State,ZIP 'relc hone
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...........❑
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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
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 Ottncr's or Authonrcd Agent's Nnnrc(L.Icclnnuc Si ❑amlff) Date
NOTES:
I. :1n Owner who obtains a building permit to do his her own work•or an owner who hires an unregistered contractor
(nut registered in the Hume Improvement C untractur(HIC) Program),will rrrr have access to the arbitration
program or guaranty fund under.I.G.L. c. 142A. Other important information on the HIC Program can be round at
tt is tt IIIA", ;;Ot ,,.,i Information on the Construction Supervisor License can be found at mi,�
When substantial work is planned,pro\ice the information below:
Total fluor area(sy. fl.) I including garage, finished basement attics,decks or porch)
, Gross living area I sq. il.l Habitable room count--_-. _—_---- - --- --..- - --Number of fireplaces .-.— Number ofbedruonts _----
Number of bathrooms Number of half hallo -
- -
� Number of decks, porches
h)lie of cooling slsletn _. - Enclosed _ _. - __ Opera
1. "Fotal Project Square Footage' ma} he substituted titr"'I' mat Project Cost-
CITY OF S.UEN
PUBLIC PROPERTY
DEPARTMENT
LPOWZY
wwe ��e vw.resoM.rnaa.s�,,,a M�o�aRsern atr.s
rti s->F�,s.ssss.F..,c nar,asw
HOMEOWNER LICENSE EXEINMION
Piss" prime
Dam
Job Location
Home Owner Address
Horns Owner TelgAtive ! 1755 -7 -7.3 3 Z 91F 9 7
Present Maiiliag Address ff 4L:6 j !1 ,0,VA . S"gl-Em NlA
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
hire who.does not possess a license,provided that the owner act@ ere supervisor.
DEFzNM0N OF H0ME0WNEIIi
person(s)who owns at parcel of land on which hetlshe reside@ or intends to resider on
which then is, or is intended to be, a one or two tinily dwelling; attached or detached
structures accessory to such use and/or firm structures. A persos who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner'shall submit to the Building OiN64 on a form acceptable to the wilding
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 regWadons.
The undersigned "homeowner"certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
mill comply with said procedures and requirements.
HO.%IEOW%iERS SIGNATURE
APPROVAL OF BUILDING NSPECTOR
See other side for state code