16 LINDEN ST - BUILDING INSPECTION II� The Commonwealth uf'Massachusetts
G/ 4 Board ul'Building Regulations and Standards CITY
d Ill Massachusetts State Building Code, 780 CMR, 7'edition OF SALEM
Rrs•irrr/Junurvr
Building Permit Application To Construct, Repair, . enuvate Or Demolish a
nr-or Twu-Funnily Dw Irrg
This Section For gelcial Use Only
fBu Permit Number• ate Applied: O
e: Huildin Cummissr r ar of Buildings f}ata
SECTION 1:SITE INFORMATION
�rry Address: 1.2 Assessor Map dt Parcel NumberL/ den, S'4is an acce ted street? es no Map Number Parcel Number
ng lotermatbo: 1.4 Property Dimensions:
trict Proposed Use LdArea(sq 11) Frontage(11)
lag SetDaelu(R)
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 O Private❑ Zone: — Outside Flood Zone?- Municipal❑ On site disposal system O
Cheek if yesO
SECTION 2: PROPERTY OWNERSHIP'
2 1 woe 'of Rao
Ate -2 /67 Ltnaeh Sf-
(Pri Address far Service:
7 —.5 u/ "'�09�
ignatu`e Telephone
SECTION D: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building O Owner-Occupied ❑ Repairs(s) ❑ Alterstion(s) O Addition ❑
Demolition ❑ Accessory Bldg.O Number of Unit_ Other O Specify:
Brief D scription of Proposed Work':
/ �> �� a�
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Otllclal Use Only
Labor and Malerials
I. Building Is 1 1. Building Permit Fee: f Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
2.Total Project Cost (Item 6)x multiplier "T
J. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) Is 1 List:
r
S. Mechanical (Fire S
tiu «ssion Total All Feet: f
Check No. Check Amount: Cash Amount:
6. Total Project Cost S u6 ❑Paid in Full 0 Outstanding Balance Due:
SECTIONS. CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor ICSL)
I.iccnse Number Expiration Dife
Name ul'CSI.-I kidder I.isl CSL Type Isee below)
f I I)escruxion
Address U tlntestricted u to35.000 Cu. FI.
R Restricted I& Family Duelling
Signature M I Masonry Only
RC Residential Raulin t'overin
felcphons WS Residential Window and Siding
SF Residential Solid Fuel Btrmin A liance Inslallaliun
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or IIIC Registrant Name Registration Number
Address Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. ISL 12SC(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...........O
SECTION 7n: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.
Fbathmums
urc of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
�a NA2 rg Lo®C � ,as Owner or Authorized Agent hereby declare
the statements and information on the foregoing application are We and accurate,to the best of my knowledge and
lf.Nurc fOwner or Authorized Agentunder the ins aid nalties of 'uNOTES:
n 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 do have access to the arbitration
rogram or guaranty fund under M.G.L.c. IJ2A.Other important information on the HIC Program and
onstruction Supervisor Licensing(CSL)can be found in 790 CMR Regulations I IO.R6 and I IO.RS,respectively.
hen substantial work is planned,provide the information below:
floors area ISq.Ft.) (including garage, finished basement/attics.decks or porch)
living area(Sq.Ft.) Habitable room count
er of fireplaces Number of bedrooms
er of bathmums Number of half/baths
f heating system Number of decks/porches
f cooling system Enclosed Open
). "Total Project Square Footage"maybe substituted for"Total Project Cost"
CITY OF &U.E."I
PUBLIC PROPERTY
DEPARTtifENT
K1fOkfliY f1�w•.y.
VAVON 1 9YAau1+[.�oM 471tsr•&%L1K.MAMACHL3WM 019'e
TI1.97.L73S-95" 9 F.-.)L 978-740.9&4
HOMEOWNER LICENSE EXE.MMON
Please "I
E)aw '10 - 1 u lC)
Job Location 1 (0 L-1 ride n Sf s4e 1-f �Q
Home Owner Addrt�s l t S er 1
Home Owner Telephone —
Pressat Mailintt Address 6 �,sae 1� SI- 4-te--{ F-vi-
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
hire who.does not possess a license,provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Persons) 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"c es that e/she understands the City of Salem
Building Department minimum i tion edures and requirements and that he/she
will comply with said procedures r u• ents.
HOMEOWNERS SIGNATL 1
APPROVAL OF BUILDINI G INSPECTOR
See other side for state code
y ,s CITY OF SALEM
-� rA ' PUBLIC PROPRERTY
DEPART'NIENT
'd 'u I-': \\ r • "All
III- /�8 �1i./iti t wC: 'i 7g.V='Li Jig
Construction Debris Disposal Affidavit
(required lirr all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 Ch'IR section I 1 L5
Dcbris, and the provisions of:b1GL e 40, S 54;
Building Permit B is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL
I 11. S 150A.
The debris will he transported by:
I name othauler) '
I lie debris will /bJe� disposed of ininn
Inamrul//auity)
Iuddre.a>ul lardny)
H L;II at UI1: of permit applicant
t/� l/y—/
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