18 KOSCIUSKO ST - BUILDING INSPECTION I
The Commonwealth of Massachusetts
Board of Building Regulations and Standards
Gy, Massachusetts State Building Code, 780 CMR, 7"edition n'
Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a 413-596-2800
(� One-or Tuo-Family Dwelling Ext 118
This Section For Official Use Only
Building Permit N /beer: Date Applied: i12f St • p'�V
Signature: '�`3-A.rS �Q ?•D f!d
Building Commissi r/Inspector of Buildings Date
_SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
IS KOSCIVSY-� SrY-E cr
I.I a 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 R) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check if yes0 Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
.l Owner'of Record:
�2t&rtNq WgcomE STF.vtelC I, Kose lt..tsl�o STtZ£ET- SAcem ara
Name(P nt Address for Service:
�� - 5o� - 4z3 - 411, z3
Sig amre Telephone
SECTION 3.DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ I Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
f Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
iefDescriptionof'•'scposed Work': -?-ISP�-PctNel gyp„K�al Stolt4CU, "FA1N-ntNCt
SECTION 4: ESTIMATED CONSTRUCTION COSTS -
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ Other Fees: $L
4. Mechanical (HVAC) $ Lis[:
5. Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ �j ,OOe .t U 0 Paid in Full 13 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL- Holder List CSL Type(see below)
Type Description
Address U Unrestricted(up to 35,000 Cu. Ft.)
R Restricted 1&2 Family Dwelling
Signature M Masons Only
RC Residential_P.00fing Coverins,__
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Dale
Signature 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 Issuance of the building permit.
Signed Affidavit Attached? Yes .......... O No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN -
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, Ve ISI N A wA Co m E STE V I C K as Owner of the subject property hereby
authorize 24--� C 69EE MTV 4 'F R A to 11 l"%(. to act on my behalf,in all matters
relative to work authorize hi build-ng permit application.
Signature of Owner Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf..
Print Name
Signature of Owner or Authorized Agent Date
Si ned under the pains and penalties of perjury
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 not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and 110.115, respectively.
2. When substantial work is planned,provide the information below:
Total Floors 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 half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF &UEM
PUBLIC PROPERTY
DEPARTMENT
K1OI�ev evww
NwVOR 130wAS OWrON S IELT•SAtmf,NANAafl.'ShM 01970
TEL.97 US-9S" FAx 978-740.9846
HOMEOWNER LICENSE EXEM"ION
Please Print
Date /0 . 21• G!&-
Job Location IC4 koscwSka-
Home Owner Address iq i[p s c- %s&y-s s-ry-g£,-
Home Owner Telephone 5 o s• - 4 2-s - H g Z-3
Present Mailing Address L& ICo s c s k s Ta-E f i
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or less and to allow such homeowners to engage an individual for
hire who.does not possess a license,provided that the owner acts as supervisor.
DEFINITION 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"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 "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 r uirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SALEM
PUBLIC. PROPRERTY
DEPARTMENT
( t)nstru�tion Debris Disposal .affidavit
(rc\luired li,r all demolition and rcno\ation \\ork)
In accordance \\ith the sixth edition of tlrc Slate Building Code, 780 C'AIR section I 1 1 .5
Dcbris, and the pro\isions of AIGL c 40, S 543
building Permit t is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by vIGL c
I 11. S 1 50A.
The deh)'is will be transported by:
I name ut hauler)
Ilie debris will be disposed ofin
luamr ul laclhty)
IudJre<.IIII�cl Ltyl / / I,
r
/NCIWIpIc oft 11clnnt epphcant
111 ,Ill