8 ISLAND AVE - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
ii Board of Building Regulations and Standards CI I 1 OF
G `y Massachusetts State Building Code, 780 CMR SALLM
I �•`�" Revised.11ur 2011
Building Permit Application To Construct, Repair, Renovate Or Dell i a
One- or Tivu-Family Drellhkir
This Section For Offlcia se Only
Building Permit Number: Date pplied: _
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Pro ertx Address: 1.2 Assessors Map& Parcel Number
lens-
I.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provide)
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? Municipal ❑ On site disposal system ❑
Check ifycs❑
SECTION 2: PROPERTY OWNERSHIP'
1 Owner'of Recor4
N;une(Print) City.Store,ZIP
No.mid Street Telephone Email Addrc s J
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ ,Accessory Bldg. ❑ Number of Units_ Other ❑ Spccity:
Brief Description of Proposed W rk':
G t i
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and laterials)
1. Building S 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(item 6)x multiplier x
1. Plumbing S ?. Other Fees: S
4. Mechanical (11VAC•) S List:
5. .Mechanical (Fire S —.
Suppression) Total All Fees: S_"
Check No, Check Amount: Cash Aniount:
l,. Total Project Cost: S i 3 I �d d ❑paid in Full ❑Outstanding Balance Due: —""—
I
SECTION 5: CONS'fR11CTION SERVICES
5.1 Construction Supervisor License(C'SL)
— --- _
License Number Expiration Date
Name ol'C'SI. Ilolder
List CSL Tope(see below)
No. and Street Type Description
U I InrestricteJ(Buildings uP to 35,000 cu. 11.)
-- R Restricted 1&2 Famil Dwelling
l ityrfUN\ll.State,ZIP M Nhisofwv
RC Rootin;Covering
INS Window:mJ Siding
SF Solid Fuel Burning Appliances
1 Insulation
I'cle hone F:mail address D I Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Registration Number Rspiraion Date
I IIC'Company N:une or I IIC Registrant Name .
No. and Street
Email address
City/Town, State,ZIP 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........... ❑
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.
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
in this application is true and accurate to the best of my knowledge and understanding.
Pont Owner's or \uthuri[eJ Agent's N ne(lilectrunic 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 M.G.L.c. 1 q2A.Other important information on the HIC Program can be found at
Information on the Construction Supervisor License can be found at www.nldil �11� dlis
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. 11.) — Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half'batlts
1, pe of heating s)'stem ----_-_---- -- Number of decks, porches_-_ _-----..._---_
1')peofcoolingstslem Fnclosed Open
1. "focal Project Square Footage-may be substituted for"rotal Project Cost,
,
CITY OF SALE.Nf
PUBLIC PROPERTY
DEPARTMENT
u,s�nu�mu
Vwrw 130 WADWAG N SMEM•SA,-- VAMA00.sar77019'0
TKL 9'L7+5-95" •F.%X 93-740.964
HOMEOWNER LICENSE EXEMMON
Plesse Met
Date
Job Location -i s\a M�A U u Q— S c.-t o VVl
Home Owner Address 3 0.
Home Owner Telephone V 7'R — ") (IL1--310 5'5—
Presses Mailing Address Z3Ck" _P
The current exemption of"Homeowners"was extended to include ownar-occupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
hire who don not possess a licarss,provided that the owner acts as supervisor.
DEFzNMON OF HOMEOWNER
Person(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'shell 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
PenniL
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 Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE _
.APPROVAL OF SUMMING NSPECTOR 44,o
See other side for state code
CITY OF S.UY.NI, L*%vL-kss k -iUSE—rrs
BI;IIDLNG DEPARTMENT
110 WASHNGTON STREET, 3iO FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KL%C3ERtBY DRISCOLL
,MAYOR THO&As ST.Pmaaa
DIRECTOR OF PLBLIC PROPERTY/Bt:II.DLNG Commtssio.ER
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
111, S 150A.
The debris will be transported by:
S
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
9�_a co
signutureofpermitappl nt
date