4-4A ROPES ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
o\l Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7ih edition Wilbraham
�� •. Building Dept
\�\ Building Permit Application To Co Repair, Renovate Or Demolish a 413-596-2800
One- or vo-Family welling Ext 118
his Section For Official Use Only
Building Permit Number: _ \ Da Applied:
Signature: /I, 16. 0oU
Building Commi oner/ nspector of B i i Date
SECT l:SITE INFORMATION
1.1 Pr pe y-Ad�ss: 1.2 Assessors Map& Parcel Numbers
I.la Is this aJn�accepied street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning Uistnct 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 Ow�p of ecord: yo y/ra _Cl'�u� f'z� �d/� 3
Name(P nt) Address for Service
72
_ 66 7—
tgnamre Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief De'cription of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
L Building $ 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: $ k
4. Mechanical (HVAC) $ List: ,1
5. Mechanical (Fire $
Suppression) Total All Fees: $
�-y��7� Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ llVv ❑ Paid in Full ❑Outstanding Balance Due:
��� 43c &
t
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) i��S93 p -26/20/0
License Number Expiration Date
Name ol'CSL-Bolder List CSL Type(see below)
r�ox yy/2 79
Address / TDescription e . t
G - U Unrestricted(u to 35,000 Cu. ft.)
' . R Restricted 1&2 Family Dwelling
Signature p p p M Masonry Onl
6� - 5J�'aJ�T> RC Residential RoofingCovering
Telephone WS 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
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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 .......... O No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTILACTOR APPLIES FOR BUILDING PERMIT
1 _, as Owner of the subject property hereby
aut orize to act on my behalf, in all matters
relative to work authorized
by t ' ilding permit application. IT,a�lte
na aofO erSECTION 7b OWEWOR AUTHORIZED AGENT
N/T D ECLA�RA T—I—
ON _
1 ,as Owner or Authorized Agent hereby declare
that the statements and info ation on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Nam '
Signature of Owner or Authorized Agent Date
JSiZned under the�wns and penalties
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 1 I O.R6 and I IO.RS, respectively.
2. When substantial work is planned, provide the information below:
Total floors area(Sq. Ft) (including garage, finished basement/aitics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halfibaths
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
PUBLIC PROPRERTY
i v'JS
DEPARTMENT
I
•.1 .. n I.. \� 1 .11:\ . ".1;JIIr � 1\II \I. \I\ .\: •. I . • .I'I -
construction Debris Disposal Affidavit
(IkAluired lirr all dcniulition :urd reno"uiun \wrk)
In accordance ill' the sixth edition of the State Building Code, 7SU CMR section 111.5
Debris, and the prop isions of'v1GL c 40, S 54:
Building Permit if is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by N4GL c
I l I, S 150A.
The dehris will be transported by.
Inantcofhaulrr)
I he debris will be disposed of in
7� � A
��l IIaI TIC UI 1ac 1111�')
IadJrm<� ul I]cJuvl
.Icnal • of prnnrt .y\phcaut
CITY OF SM.E.N1
PUBLIC PROPERTY
DEPARTMENT
� nu:u r.Y naw•v L
MAYM 130 WA9aNGTON STMERf•SAt.ew,NASWMS6m 01970
TEL 976.704S"• F..Y.978.740-96"
HOMEOWNER LICENSE EXEMPTION
Pies" Print
Data L OS
n n
Job Locationiy
Home Owner Address � c�S� 4 3
Homeowner Telephone
Present Mailing Address 1Gl 4tzr v+—w e arx "7,la� A-l/f
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 detaches!.
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
OfI•tcial, 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 requirement .
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code