3 ISLAND AVE - BUILDING INSPECTION (2) CK _�q_
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALENI
Revised Mar 2011
Building Permit Application"ro Construct, Repair, Renovate Or Demolish a
One-or Two-Fanrdly Dwelling
This Section FVMfficial Use Only .
Building Permit Number: Date.Applied:
Building 017iciul(Print Name). Signature- - . - ate
SECTION l-SITE INFORMATION
1.1 Property Address: ,/I L)e- 1.2 Assessors i31ap Sr Parcel Numbers
Z's I_A-n� {-r
I.I a Is this an accepted street?yes_ no hlap Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(It)
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 OWNERSHIP"
2.1 Ow cry of Record:
�l C3 Lr (KA— 019 �
ine(Print) City,State,ZIP
2a :J75/4 , q ?k 9a.'? ab aZ M rZ A,-C.C�-ra 00rh
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building g Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work'-:
T� o
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building $ T bO0 I. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical .$
Oo o ❑.Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S a S00 1. Other Fees: $
4. ,Mechanical (FIVAC) $ List:
5. Mechanical (Fire $
Su ression) Total All Fees:$
Check No._Check Amount: Cash Amount•.
6. 'Fufal Project Cost: $ �0 S�O 0 Paid in Full ❑Outstandim Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL[folder
List CSL'fype(see below)
No.and Street Type Description -
U Unrestricted(Buildings tip to 35,000 cu. It.)
R Restricted 1&2 Family Dwelling
Citylfown,State,ZIP Ivl "Alsonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
'fcle hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
I1IC Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State,ZIP 'rete hone
SECTION 6:WORKERS'CONIPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.g 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
1,as Owner of the subject property,hereby authorize
t9 act on my behalf, in all matters relative to work authorized by this building permit application.
/Lez� L IJ 0
Print Owner's Name(ETectronic Signature) Date
SECTION 7b:OWNERu 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 Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. .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 Flome 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.gov:'oca Information on the Construction Supervisor License can be found at vvk�w.nlass.aov/d Is
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
'rype of heating system Nunnber of decks/porches
Type orcoolingsystem Enclosed Open
3. "rotal Project Square Footage"may be substituted for"Total Project Cost'
i
CITY OF S�UI E1d, i�I.�SSACHL'SETTS
BUILDNG DEPARTMENT
P 130 WASHNGTON STREET, 3' FLOOR
TEL (978) 745-9595
FA-Y(978) 740-9846
KIJiBERL F-Y DRISCOLL
�LtYOR THostAs ST.PMRRE
DIRECTOR OF PUBLIC PROPERTY/9I;ILDL`'G CONNISSIONER
Construction Debris Disposal 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 c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11, S I50A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
__----_ (name of facility)
(address of facility)
i
Cn AA
-
signature of ei it applicant
/a 413
date
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CITY OF S,U-E%f
PUBLIC PROPERTY
DEPARTMENT
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HOMEOWNER LICLNSB E. E.l- "10,V
Please Pont
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Date o � i i 3 r
lob Lacsdora S !6 n 1 �,
Homy ownwAddrear ! — s w� DQ-7G
HomoOwroerTelaphone a�$ — 9a7— zc5z2
Psms"Madbilf Address 5&*L-
T he current esempdon of"Homeowaste wag eatendad to imhtde awaer-aacupiad
dwellings of two Units or feu assd to Allow such homaowaem to enpp m irsdividual fat
him who daft not poaaose a ficmaelo provided that the owner acts am aaperWxw.
DEFII MON Ol HOMHOWM
PeM00) who awns a pared of lead on which Wshe resides or Intends to reddsy an
which there Is, or is intended to be, a cce.or two lhmily dwelling attached of detached
reruenuea accessory to such use and/or fares Micturx A Pawn who consituOU more
than one home in a two you period shall not be considered a homeowner. Such
"homeowaes" hap submit to the Suildinb OQlcial,on s form acaptabfs to the Ssuldinb
Official, that hdahe be responsible for all such wart performed under
Permit the Building
The undersitrsed "homeownd'usumes responsibility forcomplinvot with the State
Suildinti Code and othet rpplicable bylaws rnd repuladona
The undenigned "homeowner"certifies that hdshe understands the City of Salem
Buildint Oepartrnent minimum inrpecrion procedures and requirements and that he/she
mill comply with said procedures utd requirements,
HOS1EObV`�ER3 S[G;lA TGRB
kPPROVAL OF eUILD!`lG I,rSPECTOR /ltrn�
Sce odtcr side for slue code