146 MARLBOROUGH RD - BUILDING INSPECTION (5) t The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
Gy, Massachusetts State Building Code, 780 CMR, 7"edition Wilbraham
Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a 413-596-2800
One- or Two-Family Dwelling Ext 118
This Section For Official Use Only
Building Permit Num er: Date Applied: G] • 2C(•000
LQC� / e
Signature: ( lJ, !. Q
Building o missioner/Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
�kra W1 �e�+ ak Rc�
1.1 a Ir:this an accepted street'?yes__�L no Map Number Parcel Number
1.39pZoning Information: , 1 l.4 -Property Dimensions:.
-I g 1 -_
�onmg District Proposed Use Lot Area(sq tt) Frontage(ftj
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:
Zone: _ Outside Flood Zone?
Public Private❑ Check if yeiO Municipal On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
-albr-4 Yri b rc,u"L
N e rint) Address for Service:
97T
SiK Telephone
TION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building Owner-Occupied Repairs(s) O 1 Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. Number of Units Other ❑ Specify:
Brief Description of Proposed Work': T_wsTml.L, G-w& Ftr-e.Pp c_e_ Snlse'
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Co sts:
Item Labor and Materials Official Use Only
1. B tng r-jp ' $ Q Q O 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical g
❑Total Project Costa(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:
6. Total Project Cost: $ -Z 2 0 b 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) `� t
License Number Expiration Date
Name of CSL-Holder List CSL Type(see below)
Type Description
Address U Unrestricted u to 35,000 Cu. Ft.)
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
rERC Residential Roofin Coverin
Telephone S 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 Date
I 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 .......... ❑ No........... ❑
SECTION 7a: 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 author zed by this building permit application..
Signature of Owner Date _
CTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1 _ ,as Owner or Authorized Agent hereby declare
that th s tements a d in ormation on the foregoing application are true and accurate, to the best of my knowledge and
behalf. _ n
TI CCM rJ
JSigre
ZL a
caner r uthorized Ag tDate
der the ._nd 2e.,alties of perjury)_._,.._,_._.
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and I I O.RS, respectively.
2. When substantial work is planned, provide the information below:
Total Floors area(Sq. Ft.) (including garage, finished basementlattics,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 S UY.M
PUBLIC PROPERTY
DEPARTMENT
IgfOl�L�D=wvt1�
130 WASUNG"TMEiT•SALM MASSAA/L'S✓tTiS 01978
T'ELV..L704S" 0 F.uc:979.7-4.984
HOMEOWNER LICENSE EXEMPTION
Pleas Print
Date 9 26 O� _
7obLocatka �99 7h5r1 �af `�"�� RGI \ro 4 vv" md, �197t�
Home Owns Address
Home Owner Telephone col
Present Mailing Address lzmlti c
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 d requiremrnts.
HO.MEO WNERS,SIGNATLTRE
APPROVAL OF BUILDING LIIS CTOR
See other side for state code
CITY OF SALEM
y z"
7 PUBLIC PROPRERTY
DEPARTMENT
Construction Debris Disposal Affidavit
(rc(luired liir all demolition and renovation work)
In accordance \ith the sixth edition of the State Building Code, 780 CINR section 1 1 1.5
Dcbris, and the provisions of vIGL c 40, S 54;
Building Permit it- is issued with the condition that the debris rrsultin� from
this work shall he disposed of in a properly licensed waste disposal I'acility as defined by MGL c
II1. S 150A.
The debris will be transported by:
SQ�)�
UIJmc of hauler)
The debris will be disposed of in
I nJmr ul 18cllny)
IadJre;� ut l�clluvl
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