225 NORTH ST - BUILDING INSPECTION i
The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
�y Massachusetts State Building Code, 780 CMR, 7ih edition Wilbraham
Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a 4I3-596-2800
r� One- or Two-Family Dwelling Ext 118
This Section For Official Use Only
Building Permit Num r. Date Applied:
Signature: zqeo�2 14
Building Commissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
was Noy fh Si. �rlewt MA oIR7o
---
1.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zonin¢District Proposed Use Lot Area(sq 6 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 yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
S05huo be( fv d2511/or o\ s-f. Sa Jf hr, om
Name(Pri t) Address for Service:
218 4,�-° -7537
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Constmetion❑ Existing Building❑ Owner-Occupied P! I Repairs(s) Er I Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': Ft t' Fro w>t of ew /oor &w6k, ft),firt4s
o f1d 5vpport.
SECTION 4: ESTIMATED CONSTRUCTION COSTS
km Estimated Costs: Official Use Only
Labor and Materials
uilding $ L1000 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical g ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
v Check No. Check Amount: Cash Amount:
6. Total Project Cos[: $ / ❑Paid in Full ❑ Outstanding Balance Due:
Y 5, � ro Ylo�,e uK
! 1
SECTION 5: 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(u2 to 35,000 Cu. FtJ
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC Residential RoofingCovering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel BurningAppliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name .Registration Number -
Address
Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.g 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 �p�/tucc lTG 1�1rG(Q as Owner of the subject property hereby
authorize to act on my behalf, in all matters
relative to work authorized by this building perm;!application.
--
Si nature of Owner Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
1 ,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
(Signed under the pains and penalties ofperjury)
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 110.116 and I I0.115, 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 SAI,04
PUBLIC PROPERTY
DEPARTMENT
K1fOklliY fyw•,v L .
Nwroa 13D w,mWAGrow STREW• S.u.ex MAMAC HLssrts 01970
TEL 973-745-959S 9 F%x 978-746984
HOMEOWNER LICENSE EXEMPTION
Plow Print
Date f O -Q-
l-
Job Location �a-� Nor Sf sa I e r-\ fi A Orrr D
Home Owner Address me
Home Owner Telephone of 7 S XO 1
Present Mailing Address Sct M 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
him who.does not possess a license,provided that the owner acts as supervisor.
DEF124MON 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 dwellin& 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 requirements.
HOMEOWNERS SIGNATURE P
APPROVAL OF BUILDNG JINSPECTOR
See other side for state code
CITY OF SALEM
w :
PUBLIC PROPRERTY
DEPAR"I'�tENT
(construction Debris Disposal Affidavit
(required lirr all demolition and renovation work)
In accordance ill, the sixth edition of the State Building Code, 780 CNIR section I 1 1.5
Dcbris, and the provisions of MGL c 40, S 54:
Building Permit it- is issued with the condition that the debris resulting from
this work shall he disposed of in it prupurly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
Jua 6-cr,Pa Vj
I name of hauler)
I he debris will be disposed of in
�o SIGi� cod,�
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laddres. ul lawlrtvl
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acnolwc oY permit applicant
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