2 OUTLOOK HL - BUILDING INSPECTION H -Z ll2
C�- The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY M
Massachusetts State Building Code,780 CMR SdMar
—�-+ Revised Mar 2011
_1 Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied;' '
Budding Official(Print Naive) '*' Signature; '' ly
SECTION.1:SITE FORMATION - i
1.1 P operty A dress• 1.2 As sors Map&Parcel Numbers
2 ou )o 6k Ifi I
1.1 a Is this an accepted street?yes_ no Map Number Parcel Number D
1.3 oning Information: 1.4 perty Dimensions: 4�
Zoning D Proposed Use Lot Area(sq Frontage(11) 1=
1.5 Building Setbacks(it)
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? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP''
2. wn ert off Recor S 4 le rn m 6 Q / b - -
Name(Print) City,State,ZIP
(P � )
0l I+100k— )/ VY (oat 2P �e{K�ar9cY� �prineis, orC�
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ ingBuilding❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
[E.isl
ssory Bldg.Cl Number of Units_ Other ❑ Specify:
--� BriefDescriptionofProposdWork':
IhSklllR>inYl D7 about drOUn ay rr} Eouiol c1A)(mm62J 1?06
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs:(Labor and Materials Official Use Only
1.Building $ yOD O t O O 1. Building Permit Fee:$ , Indicate how fee is determined:
2.Electrical $ 7 0 U. U Q ❑Standard. City/Town Application Fes
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ ;List:
5.Mechanical (Fire $ TOtat All Fees:$
ression
Cheek No. Cheek Amount: Cash Amount: t
6.To 1 Project Cost: $ 5700,/ 0 0 ❑Paid in Full ❑Outstanding Balance Due:'
5tr1vT� ,u NovS�
SECTION 5: CONSTRUCTION SERVICES 1
5.1 Construction Supervisor License(CSL)
License Number Expiration Date '
Name of CSL Holder
List CSL Type(see below)
No.and Street Type ,Description
U I Unrestricted(Buildings up to 35,000 cu.ft.
R I Restricted 1&2 Family Dwelling
City/fown,State,ZIP M Masonry
h
RC I Roofing Covering
WS I Window and Siding
SF Solid Fuel Burning Appliances
s--
I Insulation
' 'Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
a <+
e
HIC Registration Number Expiration 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 Tat 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 ame(ElectiVnic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) 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.mms.eov,'oca Information on the Construction Supervisor License can be found at www.mass.>ovt., ldns
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 haWbaths
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 SALEM, MASSAC HUSE TTS
BUILDING DEPARTMENT
120 WASHiNGTON STREET,3" FLooR
.s%
TEL. (978)745-9595
FAX(978)740-9946
KIMBERLEY DRISCOLL
MAYOR TYiOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date - l oh U
Job Location � o u-MU c*— ) I S(41(-m MTT o� c1 /
Home Owner Address
Present Mailing Address
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 LN /F
APPROVAL OF BUILDING INSPECTOR
,i.
N/F
it N/F \ JOHN KELLEY
CHARLES SANSONE
71.62• LOT 156
LOT 157
LOT 159
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N
LOT 160 o~
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n
041
7'fz TIHF+ LOT 158
E%ISTING
i OWEWNG
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�•� 70.00 /
C1LJT"LClC7K " ILL
ALL TIES SUBJECT TO WHAT AN ACCURATE INSTRUMENT
SURVEY WOULD REVEAL. THIS MORTGAGE INSPECTION PLAN
IS NOT TO BE USED FOR PROPERTY LINE DETERMINATION,
THE LOCATION OF FENCES OR THE LOCATION OF ANY OTHER MORTGAGE INSPECTION PLAN
STRUCTURES. THIS CERTIFICATION. IS MADE TO: BEVERLY
COOPERATIVE BANK AND BECOMES NULL AND VOID UPON 2 OUTLOOK HILL
FUTURE CONVEYANCE.
I HEREBY CERTIFY THAT I HAVE EXAMINED THE PREMISES SALEM, MASS.
AND ALL BUILDINGS ARE LOCATED ON THE GROUND AS
SHOWN. I FURTHER CERTIFY THAT THE PRINCIPAL BUILDING,
WHEN CONSTRUCTED, DID NOT CONFORM TO THE
DIMENSIONAL ZONING LAWS OF: SALEM OR IS EXEMPT FROM
VIOLATION ENFORCEMENT ACTION UNDER G.L TITLE VII S
CHAPTER 40A SECTION 7.
I HEREBY CERTIFY THAT THE DWELLING IS / IS NOT yd' g�ygpg IS HALL STREET,MEDFORD,MASS. D215
LOCATED IN AN ESTABLISHED FLOOD HAZARD AREA. k 781.396.4466 BWt781.396.8052
COMMUNITY No.: 250102
REVISION DATE: JULY 3, 2012 0 �#36 64 �i�e SCALE: 1° = 40'
864 e
TITLE REF: 8K 5542 PG 627
/1 q��__ �I jZll�l� 'Pd1 �v• DATE: NOVEMBER 21, 2013
RICHARHAR7DJ.J. '-MEDE JR., P.L.S. DATE: 11 Z '� FILE No. 629-13