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319 JEFFERSON AVE - BUILDING INSPECTION
I� I'Ite Conuno I%veaIll of Massa husclts Board of luilding Regulations and St,mdards CI'I'1' OF Boa s Massachusetts State Building Code, 780 C NIR S•\LI"',\I ltcri,dd t 6rr Jnll Building Permit r\ppiication 'ro Construct, Rcpair, Renovate Or Demolish a (brt•- fir TuvFwndt• Dwdlirr,Cr This Section For 011icial .e Ottl Building Permit Number: Date 1 pplied: Building 01111cial(Print Share) Signature ly Dale SECTION I:SITE INFORMATION 1.1 Pro ert A rest•. I,I Assessors Slap d's Parcel Numbers 1.la Is this an aece ted street? es no khtp Number Purccl Number 1.3 Zoning Information: 1.4 Property Dimensions: Loning District Proposed Use Lot Arca IN 11) Fronlage Ili) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.1.c. 40.5 Sa) 1.7 Flood Zone Information: 1.3 Sewage Disposal System: Ihtblic❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal%)atom ❑ Check il' esO SECTION 2: PROPERTY OWNERSHIP' I.1 O�w of oft f Record Lf/iLi1 Q / 0f 7-0 Nam • Print) City.State,ZIP �l 9 � >°�3 Gn• en 7o7 SG N�In� �Aj relephone Email Addruss SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ TExisting Building❑ Owner-Occupied ❑ Repairsis) ❑ Alterallon(s) ❑ 1 Addition ❑ Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other Cl .Spucily: Brief D 'Proposed Work=: X=Ce_ I r SECTION a: ESTIMATED CONSTRUCTION COSTS (tent Estimated Costs: I Oft NI Use Only (Labor and \laterials) I Building S 1 I. Building Permit Fee: S Indicate how Fee is determined: 1:'lairieal S ❑Standard CityTo,sn Application Fee '. ❑Total Project C'uitr(Item 6).x multiplier _ . x ). 19uniMng S '. Other Fecs: S 1. \lech.utical 111\ \('1 $ Lisl:_- ----- �u „rcssiont Fatal .\ll Foes: S_ � ('hccA No. ( hcck Amount: C'.teh \nunmt: ©a a 1'utal I'rnjcct Cost: S yJ � ❑ Paid in Full O Outstanding 11.1l.ulce Due: SEX FION3: CONSFRIlcrIONSERVICFS 5.1 Construction 5upen isor License(CSL) A L's I. [,.%fv(Sev PC lkseriplion t I I Itimstricicd I Iloildilitis(10 to 15.000 0 It I Restricted 114L2 Faillil) I)o0fing (711-)--7FTE11111.Fate.LII' an RC' Rrenin Cos 11 it ding LSF Solid Fuel Ilumins Applijoccs I Insulation I VIVI,holo: Fowil address 5.2 Registered Illurne Improvement Contractor 11110 IIIC Registration Number F N11iralion Wic 1 IIC Compaii) Name or I IIC 14,:gisirant Nino: No. and Street Ernuil address City/Town, State,ZIP relephona I I SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 153.1 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this af(Idavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes .......... a No...........0 SECTION In: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 Uwicr's Nunia(EIccirunic4iiinutum) Data 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""I contained in this is true accurate to the best of my knowledge and understanding. 61 01-2- In-ic Print Ooncr'i lit-Vithori/ed Av,I*i Nal 114 1 F I Cctrkolic sivilawro) r.4 r NOTES: I. A O"ller n 0%%oer who obtains a building permit to do his.her u%vn work,uran owner who hires an unregistered cummoor I'Jut registered I not registered in the Hume Improvement Contractor(HIC) Program). will tajp have access to the arbitration program ur 0 prograin ur guaranty fund utider.M.G.L.c. 142.A. Other important information on the HIC Program can be l'ound at ;0% 01 1 Information on the Construction Supervisor License can be found at ( is planned, provide the infurmation below: row flour area(s+ 11.) (including garage. finished basemen:attics.dCt:k$ or rordi) Gross li%log area i iq. tl.i Habitable rouni count Nuillher ol'bedrooms \timberot'hathrooms \o1litivt ol hall hilth'i 1wof1w.1ting SN'leitl \twihvro(d%xks, por0ics lroje" Squarc Foolacc-ma% he •tjb,muted flor lotal Projed 01,1- CITY OF S.UYENf PUBLIC PROPERTY DEPART IENP ai usuast a•uruu. ` AVM i]0 v�•w srrwr•s�uy V�saoe ssrss Otre rta.rtins.�sr! • r..a.r.tir+o•�w HOMEOWNER LICLNSZ EXE.I4PTION P1nN hint ow G Jab tocadoes Home Owner Addrar Homo OMW Telepbmo Prssom Ma&s Addrtsr The current exemption of"Homeowners"was extended to include owner-occupied dwellings of two Units or tern and to allow such homeowners to engage an individual for hire wbo dam not possess a litatso provided that the owner acts as suplems,or. DEFINITION OF HOhMOWNER Persona) who owns a par A otland on which he/she resides or intards to raids, on which them h6 or is intended to bq a one or two firmly dweWng, attached or detached stnaenses accessory to such use andlor farm structure. A person who constructs more thaw one home in a two year period shall not be considered a homeowner. Such "homeowned'shall submit to the Building OQi64 on a form acceptable to the Building 0Cllcia4 that he/she be responsible for all such work performed under the Building Permit The undersigned "homeowner"asaturnes 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 Bwlding Department minimum inspection procedures and requirements and that he/she .vill comply with said procedures and requir tt HOMEOWNERS SIGNATURE .APPROVAL OF BUILDING MPECTOR , a See other side far state coda CITY OF sm-E+i, AUSACHUSETTS 8L'ILOLNG OEPAA-ntL%r 110 WAiHNGTON SrUmr, }r FtOOIt I*EL k973) 74S.9599 KIM®EFU V ORISCOLL P.Vc(978) 7a49846 .MAYOR MO.MIU ST.PMUS O mwrO!<OP Pt BLIc PROP!llTY/St:=LYG CO\MISSION EA Construction Debris Disp0331 Af ldavit (required for all demolition and renovation work) to accordance with the sixth edition of the State Building Code, 730 CMR section 111.S Debris, and the provisions of MGL o 40, S 54; Building Permit a is issued with the condition that the debris resulting from this work.shell be disposed of in a property licemed waste disposal facility as defined by NIGL c 111, S 150A. The debris will be transported by: (n+ma of hauler) The debris will be disposed of in : (nama of rustily) (rddreei of qu+l++y) +yn�mreofpermitippl+urnt - -k a J�+a