7 ISLAND AVE - BUILDING INSPECTION �3 q1D- I . q l z $12-4all,
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards Q Massachusetts State Building Code,730 CNIR SALENI
Revised.blur 2011
p Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divel ing
This Section For Official Use Only
Building Permit Number: Date.A lied: III — )
Building Official(Print Name). Signature- Date
SECTION C:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
I.la Is this an accepted street?yes i� no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Q PS < Till
Zoning District Proposed Use Lot Area(sq R) Frontage(11)
1.5 Building Setbacks(ft) ,\
Front Yard Side Yards Rear Yard
Required Provided Required Provide) Required Provided
1.6 Water Supply:(M.G.L a 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Di osal System:
/ Zone: _ Outside Flood Zone?
nicipal Public L9' Private❑ Check ifyes❑ Mu On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2. Ownert of Record
ht,ri f� Z . 24-7()
ghme(Prmt) /� City,State,ZIP
anG1 IF e IGAsihnht.,G7C'c�m r;
No.and Street Telephone L•mail r1 ress
SECTION 3: DESCRIPTION OF PROPOSED WORK°(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied 91Repairs(s) cri Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other U;I-Specify:
Brief Description of Proposed Work'-: �'j.�.f it ,A
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Itch Official Use Only
Labor and Materials
I. Building S 10 U JO. C+(; 1. Building Permit Fee:S Indicate how fee is determined:
Electrical S ❑Standard City/Town Application Fee
(U2 CC ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S t ?, Other Fees: $
4.Mechanical (FIVAC) S List:
5. Nlechanical (Fire S
Su ression) 'Total All Fees:S
Check No._Check Amount: Cash Amount:
6. Total Project Cost: S I 0 Paid in Full ❑Outstanding Balance Due: .
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of C'S L[folder
List CSL Type(see below)
No.and Street Type_ Description
U Unrestricted Buildings Lip to 35,000 cu. R.)
R Restricted 1&2 Family Dwelling
Citylfown,State,ZIP NI Nfasonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
'rcle Iwnc Email address D Demolition
5.2 Registered Home n Im1proventen Contractor(HIC)
�C�4� I�t t uC V"1 �xty� C�).'�S FIIC Registration Number Expiration Date
-HIC Coryttt-7tlin^y^ imc or i 11 IL K snam Name
Yl1t Uf j , IlQ=
No. and Street
OA,7 Email address
City/Town,State,21P Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G,L.c. 152.¢ 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 Iskuance 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.PERAIIT
I,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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
cost in this do is true and accurate to the best of my knowledge and understanding.
con
il��rllc n 111121132
Pri Eir 1 v L Authori> A e is 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 Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under ibLG.L.c. I42A.Other important information on the HIC Program can be found at
wyxvw.mass.1 ov'oca Information on the Construction Supervisor License can be found at wtctv.mass.aov'd)S
2. When substantial work is planned,provide the information below:
Total floor area(sq. R.) (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 healing system Number of decks/porches
Type of cooling system Enclosed Open
3. '"total Project Square Footage"may be substituted for"fatal Project Cost"
: �4 r CITY OF SMLEM) ENSSACHUSETTS
13UIMLNGDEP.IRT\IEVT
130 WASHNGTON STREET, 3''°FLOOR
' = TEL (978) 745-9595
F.tiY(978) 740-9844
K1JiBF_RLEY DRISCOLL
,bL4YO;i Tmo.Nw ST.Pr RR
DIRECTOR OF PUBLIC PROPERTY/BUILDQYG CO\O(I5SIONER
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 t 11.5
Debris, and the provisions of tNIGL c 40, S 54;
Building Permit k 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 tMGL c
l 11, S 150A.
The debris will be transported by:
I
C^ f, G �lrt/ICS
(flame ut bauler)
The debris will be disposed of in
(name of facility)
_----(address of facility)
/ G
s mature of7 %L
pe'mit applicant
=�—— —
1 (/ Ilatc
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CITY OF S.U-&Nf
PU13UC PROPERTY
DEPARnj IENT
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H0ME0WNER LICENSE CXE.M"101*4
Pteesat lHaf .
Data 1 I
lob Uesdois
Home O*Mar Addtaot ihP
How OmwTelepboas 7r ��X• �cZ[�
Present Dialling Address 7 7.1,.
Tie current exemption of"Homeoavnere was extersded to inchtde owner-occupied
dweWnys oth"Units or fear and to Allow Anil homeowners to Capp>o individual for
him who does not possess A licsns4 provided that the owner acts as Apesvisor.
DEF NMON Ol HOMHOWNEA
Person(s) who owns a petrel otfsod cis whinb ltdsba redder or Intends to resider os whicb then Is, or is intended to ber a oea or two Ihmily dweWng, Attached or detsehed,Jwxnw% accessory to such use and/or raw rrrotuseat, A Peron who comttucto more
than one home in a two year period shall not be considered a homeowner. Sueb
„homeowner"shall submit to the Building 001441, on A fora Acceptable to that Building
OPAdal, that hdshe be responsible for all such wart performed under that Building
Permit
The undersigned "homtownd'unuaa responsibility for compliAms with the State Building Coda utd other applicable bylaws and relululoru
The undersigned "homeownee certifies that hdsho understands the City of Salem
91111ding Department minimum inspection procedures and requirements and that hdshe,Ni If comply with said procedure uiremmts
H01,tEOWNTRS SIG;JA R
APPROVAL OF 9UILOTYG 4`iSPECTOR
See other tide far state code