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60 MARLBOROUGH RD - BUILDING INSPECTION (2) (O t 16 cf Zg 1 The Commonwealth of Massachusetts W Board of Building Regulations and Standards RECEIY D CITY OF Massachusetts State Building Code, 780 CMRINSPECTIONAL SERVO& Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate O Derrlplj,h,t P � 33 One-or Two-Family Dwelling YY IJ��PP �1 tUJ This Section For Official Use Only Building Permit Number: Date Applied: A �Q Building Official(Print Name) Wpature D e SECTION 1:SITE INFORMATION I 1.1 Prop rty Addre s: 1.2 Assessors Map&Parcel Numbers 1.1a 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 ft) Frontage(ft) 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' 2.1 Owner'of Record: JC Name(Print) City,State,ZIP ass .and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: X 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:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Costs(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: y 6.Total Project Cost: $ j i f0c ,(DO ❑Paid in Full ❑Outstanding Balance Due: /\ L0C--.)V-kr.l(a F-Of- Sf-Vr STPAZ�T I "0%D KiCIr 1ZkfAO. UJPs NoT IEV"1N� Pay S*1E jlC�NcD 0.0• ey-onvnoo FDv-rA i taXb-D i1>stz P cc - A�So- 1 u,Rs Owe V3)r\o WGFT'4- 1 ©vim TIAA.r SPEC l> 1 c 1 OR M 'Olt H N1Q (h� l� StfpJ-t- R Il� — A SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) e f License Number Expiration Date Name of CSL Holder f { A Q i I List CSL Type(see below) • �^ t216i' No.and Street `` Type Description U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted 1&2 FamilyDwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Sidin SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expnation Date HIC Company Name or HIC Registrant Name No.and Street Email address City/Town,State,ZIP 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 .......... ❑ No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 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 By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this applicationniis truuJe and accurate to the best of my knowledge and understanding. io Print Owner's or Authon d Agent's Name(Ele onic S ature) Date NOTES: 1. 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 can be found at www.m&ss. ov:oca Information on the Construction Supervisor License can be found at wwwauass.gov/dps 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 half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"maybe substituted for"Total Project Cost" 1� l QTY OF SALEM, MASSACHUSEM BUILDING DEPARTMENT 120 WASHINGTON STREET,3m FLOOR \+� TEL. (978) 745-9595 F KIMBERLEY DRISCOLL FAX(978)740-9846 MAYOR THomAS ST.PIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING CONaffSSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris, and the provisions of MGL c40, 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 deposit facility as defined by MGL c 111, S 150A. The debris will be transported by: syzH (name of hauler) The debris will be disposed of in: (name of facility) (address of facility) Signature of applicant R - io - ILf Date CITY OF SALEM, MASSACHUSETTS ` BUILDING DEPARTMENT 120 WASHINGTONSTREET,3 FLOOR TEL. (978) 745-9595 Fr\x(978) 740-9846 KINMERLEY DRISCOLL MAYOR THOMAS STTIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING COMNIISSIONER HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: Date 9 - IL) - Job Location LQ3DP_OL( 6— O'a A- 0 Home Owner Address P L Present Mailing Address S &H E 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 that 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 understand the City of Salem Building Department minimum inspection procedures and requirements and that he/she will comply with such procedures and requirements. HOMEOWNER'S SIGNATURE aAJ(�= AL�A av--> APPROVAL OF BUILDING INSPECTOR Z °