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196 JEFFERSON AVE - BUILDING INSPECTION (2) Fhe Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SALEM ReriseJ.tlur?0/l Building Permit Application To Construct, Repair. Renovate Or Demolish a One-or Trvo crm v Dwelling This Section For Official U.iV6nly Building Permit tub-e�rr:,,,, ate App ed: Building Official(Print Name ignature at SECTION l: JVrE INFORMATION 1.1 P erty Ad ess.A YJ 3 1,2 Assessors Map& Parcel Numbers I.1 a Is this an accept d street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq It) 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.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❑ S TION 2: PROPERTY OWNERSHIP' V2.1 Owner'of� Recor �t� Name(Print) ` C'ily.State.ZIP i�6 �eG SOS 7d°s'3z c, No.and S— trc�V 'telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s)X I Addition ❑ Demolition ❑ Accessory Bldg. Cl Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials) 1. Building $ 1. Building Permit Fee: S Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: $ 4. Mechanical (IIVAC') S List: iu echanical (Fire S Su. mressionl "total :MI Fees: $_ G. Tutrl Project Cos[: S 1 © D Check No. Check Amount: Cash,\mount: - fJ 69 0 Paid in Full 13 Outstanding Balance Due: --- _ SECTION 5: CONSTRUCTION SERVICES , 5.1 Construction Supervisor License(C'SL) License Number Iispirdion Date Nwnc of C'SI. I folder List CSI_Type Isee below) No. and Street -- Type Descrip' n U l Inrestricled(Buil gs u' n)15,n1ID cu. 11.) It Restricted I&? un)il Dwelling C'ilyll'o)vn. Slate.ZIP Mason RC Roo lin -oscrin WS MWi wand Siding MSF id Fuel Burning Appliances I Insulation Tcic (tone ('.mail address D Demolition 5.2 Registered Home Improvement Contractor(HIC) IIIC' Registration Number aspiration Date I IIC'Company Nmnc or I IIC Itcgislrunl � e '- ' No. and Street 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 J� OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT J(/ 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. 'riot Owner's ar��ut o ¢ed Agent's a e Hcctrunic Signature) Date NOTES: I. 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 nor have access to the arbitration program or guaranty fund under M.G.L.c. 1 4_'A.Other important information on the HIC Program can be found at ww w.ma�s.�ay oc;i Information on the Construction Supervisor License can be found at wkA_ .n ass1�on 'dh; 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 halfbalhs 1)pcofhcatingsystern _..-------_---- Number of decks, porches_ i)pe of cooling Sy Steil) Enclosed i. "Focal Project Square Footage-may be substituted ti r-ro(ai Project Cost" CITY OF S.0 EMI NL�SS.�CHL'SETTS BLLLDLNG DEPARnW.NT 120 WASHLYGTON STREET, 3i0 FLOOR TEL (978) 74S-959S FAX(978) 740.9846 ICIaBERLEY DUSCOtL MAYOR THoms ST.Pwan DIRECTOlt OF PCBIIC PROPERTY/ffi:II.DLNG CONNISSIONER Construction Debris Disposal Afriidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section l 11.5 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 1VIGL c 111, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in (name of facility) (address of facility) signature of permit applicant 07-- /2 — date -I[t1O41rt•IC CITY OF S.Umff PUBLIC PROPERTY DEPAim, IENTP w,vussr ossnaL . .Vwroa r]O v�a.+ucran trvaT•Sua+t V�a�al�smf et1'0 ItL YL7lifSfS�t'.�i f'L7l6fW HOMEOWNER LICLNS6 EXEMPTION Plesw "I Date Job Lacados Home Owner Address Home OwoesTelephone Z 0 tf e' Present Mailing Address The current exemption of"Homeowners"was extended to include ownw-occupied dwellings of two Units or lea and to allow such homeowners to engage an individual for hire who does not possess a licenser provided that the owner acts as supervisor. DEFINMON OF HOMEOWNER Persons)who owns s parcel of land on which he/she resides or intends to reside. on which there is, or is intended to ba6 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"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 PaTWL The undersigned "homeowner"assumes responsibility for compliance with the State Building Code and other applicable by-laws and reguladons. 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 BUILDING INSPECTOR Sce other side for state code