8 ISLAND AVE - BUILDING INSPECTION S --- I'lie C om monwcallh of hdassachuselts
Iloard of Building Regulations and Standards CITY OF
I If\ t + \1as.carhusctts State Building Cute, 780 CMR SALIM
r
Building Pcnnil Application To C'unslntcL Repair. Renovate Or Demolish a
One-or rive)-Fanti/Y Duc//ip \q
This Section For 01771cial Use Onl
oit�ht
it Number: Date Ap lie ,
SECTION I:SITE INFORMATIAddresu 1.1 Assessorblup Parcel NumberL19accepted street" es no Map Number Parcel Number M
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed thw Lot Area(sy II) Fmnlaye(ll)
1.5 Building Setbacks(fl)
From Yard Side Yun)s Rear Yard
Rayuimd Provided Required Provided Required Provided
1.6 Water Supply:IM.G.I.c.40,§Sa) 1.7 Flood Zone Informatlon: 1.3 Sewage Disposal System:
Public G PH%ula O Zone: _ Outside Flood Zone? Municipal O On site disposal system
Check if es0
SECTION3: PROPERTY OWNERSHIP'
� qq o r'of Records
/t�I+ 13-CL 7
Muna rint) City.State,ZIP
-1-5"/L)0 /9U6 f-2 yY-136
G Nu.a d Strcet reiephone Fmuil Address
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction Existing Building Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition a
Demolition D Accessory Bldg.O Nu f Units Other O Spocily:
Brief Descriptionofproposed Work': ri
/57
SECTION J: ESTIMATED CONSTRUCTION COSTS
Ilan Estimated Costs:
(Labor and\laterials) Official Use Only
I Building S I. Building Permit Fee: f Indicate how Ice is determined:
'. Electrical S O Standard CityrTotsn Application Fee
❑Total Project Cost'l item 6)x multiplier -- x
1. Plumbing S 12. Other Fees: S_
1. \Icchanical ill\ \(•I S List:
1 \Icchanical tfve -- --- -------- - -- --
1u rwcsiionl S I. l'utal Project Cost: S — '—
t'hcck No. ( heck Amount•. l'.i�h \nnnum:
� _g 11.11
t� ❑ P.tid in Full O Uwm;mJin Oal.mce Due:
SECTION S: ('ONSTaII("PION SF.RVIfh:S
S.I Construction Sullenisur License(C'SL)
I icemc Nunthcr _... .... I\pirdittn bale
\all to of t'S I. I lot ler _. C S I. I')pe hec he lots l.__._ — —
---'---- --- ---- 'I\pc Dcscriplian
No. .u1,1 Street It I Inm trictcd lllui loin s 10 to 3LJ0l1)al. 11 )
R iteetricteJ Lrl f,unil Dndlin
Cit\i roan..W:ue.L ' ..—._----. . . .vl Masonry
RC NlMnin C i%erin
K'S N'indon ,old SiJin
SF Solid Fuel Miming Appliances
I Insulation
I hone I`nmil jdJres D Denlowiun
3.2 Registered Ilome Improvement Contractor(HIC)
IIIC Itell6tndion Numhcr I(\pinniva Dutc
I IIC Conlin) Nanw nr I IIC Itegistrunt Name
Nu. and Slrcd Email address
Ci Down.Stale ZIP Telephone
SECTION tit WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 132.1 23CM)
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 ..........O No...........0
SECTION 77 OWNER AUTHORIZATION TO BE CONIPLETED 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.
Trial owner's Nane(Electronic Sianuturc) 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 trruue anLd accurate to the best of my knowledge and understanding.
�/ Gli4�� 7J ✓7iG/1 Fn Q
Print Owncr'i or:\ututriru acnt's N;une ic Slanamrcl
pate
NOTES:
I. An 0\tncr who obtains a building permit to do his her own \vurk,or an owner who hires an unregistered contractor
(not registered in the Hume Intprovenitnt C untractur i HICI Program),will nu have access to the arbitration
program or guaranty fund wider M.G.L.c. I12.4.other innpunant information on the HIC Program can be I'nund at
t,ua 11.1" Infornnaliun on the Construction Supervisor License can be found at It I\`\ '11"
2. tt'hen substantial work is planned,provide the inl'unnntion below:
rota) iloor area I sy. 11.1 . ____,._l including garage, finished basenont attics,decks or porchi
Grosi li\ing area i sy. tl.t _.._ ._. . .. Habitabit room count ---.
\unthcntl lireplacei Number ul hedruums
\unlherol'hmhrounns — \unlbcrtithalthaths
I\pe III heating iy aeln \unnher ot'Jecki, porches
I'ncla,eJ (teen
I 1 pC oI CI`ohllg
I
1 "loiall1wivo Square rootage nta\ 1`e+uh,ntutedfur"I\11a11'rojectCost"
CITY OF S,Vz%f, NE"s.ICHC'SETTS
JLtLDLNG OE?.IATMB,`T
I '0 WASKNGTON STXW, J A 6LOOA
ILL k973) 741•959S
1UJ�FJtLSY DRlSCOLL fru(973) 14&9844
NCAYOlt Mostu ST.?MXA t
DIMCTCit 0f PLHL1C PROPQATY/at;anLVG CON 0113310VEA
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accardance with the sixth edition of the State Building Cade, 780 CMR section 111.1
Debris, and the provisions of MGL a 40, S 54;
Building Permit At is issued with the condition that the debris resulting from
this work shall be disposed of ins properly licensed waste disposal facility as detincd by&IGL c
11 I, S I10A.
The debris will be transported by:
tn,+ma ul haulu)
The debris will be disposed of in :
(name 1�ral�;Jljly)
t,darst,or n„1„y)
nanusur;ermiripp •ins
CITY OF S.ULE.NI
PUBLIC PROPERTY
DEPARn, ENT
U fOtl�fll tirvr�
WYOe 1>0 VA"MGTM STAR 1 IMAM HAYACIft ZW }r 011e
t$9"9-745-9s"•F1.At 975•7469ow
HOMEOWNER LICENSE EXEMPTION
Pfeaw IM�t
Date y'oa6 10,
fob Loeados C" /
Home Owner Addreae_ Z SY/>'i:,D AUF
Home Owner Telephone �s�4 ySi—vG�f S
Pressw Mai11aF Address ST y:
The current exemption of"Homeowners"was extended to include ownw-occupied
dwellings at two Units or leis and to allow such homeowners to engage an individual for
hire who.dodo not possess a'leas~provided that the owner acts as supervisor.
DEFlNMON OF HOMEOWNER
Person(s)who owns a parcel o[land on which he/she resides or intends to reside.an
which there is, or is intended to bs6 a one or two &mily dwelling, attached or detached
structures accessory to such use and/or farm jWxtureL A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner"shall 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
Permit
The undersigned "homeowner'assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeownd'certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that hdshe
•Hill comply with said procedures and requirancrim
HOMEOWNERS SIGNAMM
APPROVAL OF BUILDING NSPECTCR
See other side for state code