4 SHILLABER ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code. 780 C'MR, 7i°edition OF SALEM
Revised Jurnrrrrr
Building Permit Application To Construct. Repair, Renovate Or Demolish a
One-ur Two-Fumily Dwelling
This Section For OII•icial Use Only
Building Permit N ber: I Date Applied:
Signature: :2/W/0
Building Commissioned 1 tar of Buildings Data
J SECTION I: SITE INFORMATION
I�l PpMeA so
a oil I.2 AssessorsMap m Parcel Numbers
I.1a Is this an acce ted street° es no Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
a Zoning District Proposed Use L Am(sq 11) Frontage(11)
s(11)
I.S Building Setback
P/�4NnrPj
nt Yard Side Yards Rear Yard
Provided Required Provided Required Provided
-
Frontly:(M.G.L c.40.§54) 1.7 Flood Zone Information: 1.8 Sawsgo Disposal System:
sle O Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Check if es0
' L ' SECTION 2: PROPER OWNERSHIP' p ecords 1 ( I CIRY r I r)M Q ('wl
Add fwService:
Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction O Existing Building O Owner-Occupied O Repairs(s) O Altention(s) O Addition O
Demolition O Accessory Bldg.O miser of Units_ Other O Specify:
Brie Description of posed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 011lelal Use Only
Labor and Materials
I. Building S 1. Building Permit Fee:S Indicate how fee is determined:
❑Slandard City/Town Application Fee
2. Electrical S Cl Total Project Cost'(Item 6)x multiplier x
J. Plumbing 5 2. Other Fen: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Su ression Total All Fees:S
Check No. Check Amount: Cssh Amount:
6. Total Project Cost: 5[�.� 4"d 0 Paid in Full 0 Outstanding Balance Out:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
I.1ccroc Number Fxpiration iktte
N:une of CSI.• I luldrr I.ist CSL 7)pe Isce below)
05FRt3idential
Description
.%Jdress ted to I4=t V., Ft.
1k2 Famil Uwellin
Signature ()al Routin fclepftone al l Solid Fuel Burning Appliance Installation
D Residential Demolilion
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name ur f1IC Registrant Name Registrmion Number
Address Expiration Date
Signature 'fclephwte
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.a ISL! 2SC(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...........O
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 authorized by this building permit application.
siWissure of Owner Dote
SECTION 7b:OWNERt OR AUTHORIZED AGENT DECLARATION
1 ,as Owner or Authorized Agent hereby declare
that the statement and information on the foregoing application are We and accurate,to the best of my knowledge and
b alf.
r i 0 'l aVrrn
Print Nom
. ignature of Owner or A Ihortzed Agent (hie ! �_
Si under the pains dW Penalties of 'u
NOTES:
I. An Owner who obtains a building permit to Jo his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home improvement Contractor(HIC)Program),will aag have access to the arbitration
rNumberofbathrourns
am or guaranty fund under M.G.L.c. 1 J2A. Other important information on the HIC Program and
ruction Supervisor Licensing(CSL)can be found in 7110 CMR Regulations I IO.R6 and 1 IO.RS, respectively.
2. substantial work is planned,provide the information below:
s area(Sq. Ft.) (including garage, finished basement/attics.decks or porch)
g area(Sq.Ft.) Habitable room count
f fireplaces Number of bedrooms
throoms Number of half/baths
ating system Number of decks/porches
Type of cooling system Enclosed Open
J. "Total Project Square Footage"may he substituted for"Total Project Cost"
CITY OF SALEat
PUBLIC PROPERTY
DEPAR' MENT
ou o. �
VArM 130 WAAGNGWO SMEW• &UM VAUACHLU n0n9.0
TU 9's.745.9S" 0 F.%x 976.740.9&4
HOMEOWNER LICENSE EXEMPTION
Please Print
Date -7 11"51 1 U
Job Location
Home Owner Ad&eu
Home Owner Telephone '1 Sd q"] q ,11 R
Present Mailing Address a 2
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or lest and to allow such homeowners to engage an individual for
hire who.does not possess a license,provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Peson(s) who owns a parcel of land on which he/she resides or intends to reside6 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 hdshe 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 t he/she
will comply with said procedures and requirements,,
HOMEOWNERS SIGNATI,'RE 4 ( 1
VA /
APPRO L OF BUILDING INSPECTOR r/
See other side for state code
CITY OF SALEM
i PUBLIC PROPRERTY
DEPARTMENT
'.I ii ill 12' \C.Ujjj.,..oN!,Bhf T # SAKI M, \1\1111 i! 'I I ,
Construction Debris Disposal Affidavit
(retluired Ibr all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 1 1 L5
Debris, and the provisions of MGL c 40, S 54;
Building Permit « is issued with the condition that the debris resulting front
this work shall be disposed of in a properly licensed waste disposal 13cility as defined by MGL c
l 11. S 150A.
The debris will betransported by:
1Barn of harder)
I lie debris will be disposed of in
(name of facility)
Inddress of facilim
sign ure of permit applican
date —
i Jrhn.Y do.
The Commonwealth of Massachuscus
'(hU�S Board of Building Regulations and Standards CITY
1' 'e/ ) Massachusetts State Building Code, 780 CMR, 7'"edition OF SALEM
RrwsrJJunurvr
�`7•�-� ' Building Permit Application To Cunstruct, Repair. Renovate Or Demolish a /, aMAI
One-or Two-Fumily Dwelling
This Section For Oflicial Use Only
Building Permit Number: Date Applied: �.
Signature: Y�
Itudding Commissioned Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Prop rty drew: 1.2 Assessors Map A Parcel Numbers
/ ✓'
Via Is t is an accepted slreel?yes no Map Numbs Parcel Number
I.J Zoning loformallon: 1.4 Property Mammalians:
Zoning District Proposed Use Lot Area(sq 11) Frontage(1I)
1.5 Building Setbacks(it)
From Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.ao,§31) 1.7 Rood Zone Information: 1.8 Sewage Disposal System:
Public O Private O zone: — Outside Flood Zone?Check if es0 Municipal On she disposal system O
SECTION 2: PROPERTY OWNERSNIJO
LI Owner t of Record:
Name(Print) Address for Service:
t
Signature Telephone
SECTION J:DESCRIPTION OF PROPOSED WORK'(cheek aB that apply)
New Construction O Existing Building O Owner-Occupied O 1 Repairs(s) O Alleration(s) O Addition O
Demolition O Accessory Bldg.O Number of Units_ Other O Speciry:
Brief Description of Proposed Work': rade A i
ha�f w PJNCfrir./ S�rwca
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Omelal Use only
I. Building S �'0, d d 9 1. Building Permit Fee: S Indicate how tee is determined:
2. Electrical S u e, la,
O Slandard City/Town Application Fee
O Total Project Cost'(Item 6)x multiplier x
). Plumbing S 7 0 ,J;; 2. Other Fees: S
J. Mechanical (FIVAC) S List:
3. Mechanical (Fire
suppression) S Total All Fees:S
6. Total Project Cost: S 22 ��„+. heek No._Check Amount: Cash Amount
/ Paid in Full O Outstanding Balance Due:
r.
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction SupervisorICSL) eS'F 3 t!
_rtk )7 I.ircnse NwnM Fipimtion Duce
N. Milder ul L'Sl..- alder t�/jJ((( I.ia CSL fype(see below)
$� !" IF Descri ion
.%Jdmss U I Inresuicted to 73.000 Cu. FI.
R Restricted 1&2 Farm 0%vilin
Si ore M M Onl
L f r RC Residential Roulin Covering
WS Residential Windo and SiJin
1'cicplw>rme SF Residential Solid Fuel a intiAtioliamcinstalialkicti
p Residential Demolition
5.2 Reghtered Home Improvement Contractor(HIC) lG/ pG �"'
Reggutration Number
I IIC on, A foams or 1114.X Lr,�nd
Ad cis ..I- ��• Expiration Due
Si UM Tclephunr
SECTION . WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. IS2./ 2S ON
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...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1. r �� d, Y 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.
J
Si ore of nor Date
SECTI N 7b- OWNEW OR AUTHORIZED AGENT DECLARATION
1 as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are We and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of owner or Authorized Agent Date
Si U114191,11111 °ins and lties of u
NOTES:
I. An Owner who obtains a building permit to do his/her own work,o►an owns who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will do have access to the arbitration
program or guaranty fund under M.G.L.c. 1 42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 7R0 CMR Regulations I IO.R6 and 110.RS,respectively.
When substantial work is planned,provide the information below:
Total it
area(Sq.Ft.) (including garage, finished basemenUanics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Numlerofbathrooms Numberofhalf7baths /
Type of healing system 9�5 5 Number of decks/porches /
T)peofcoulingsystem, Ad A) Enclosed Open r/
), "Tuial Project Square Footage"may be substituted for"Total Project Cost"
Massachusetts- Department of Public Safet
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 85893
Restricted to: 00 1,_3
t
CARLOS OTONI
8 ELSMERE TER#2
MEDFORD, MA02165 cf'
�L- is Expiration: 9/122011
(lnumk'iwirr Tr#: 11277
71W �'oa vnunu a' of'..A�laeoar/enie!!a - --_..-._ --- -- —.. - ._ —..._•.
. License or registration valid for individul use only
Office of Consumer Affairs&Business Regulation before the expiration date. If found return to:
HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation.
Registrahon 140679 10 Park Plaza-Suite 5170
Expiration P[/102011 Tr# 290519
+ .. Boston,MA 02116
Type ",=indnidual
C.CONSTRUCTION`;`* j
CARLOS OTONI . �
8 ELSMERE TERR fl2:"
MEDFORD, MA 02155 Undersecretary Not v without signature
F