26 SHILLABER ST - BUILDING INSPECTION *d
i l The Commonwealth of Nlassachusetts 4r2
1
Board of Building Regulations and Standards
ail I� Massachusetts State Building Code, 730 CMR
Revis
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
This Section For Official Use Only ✓r
Building Permit Numberr Date A phed�,. ,
r
ilding Official(Print Name) St naC �?
SECTION L SITE IN R6G1 . 0N_
L roperty Address: L2 Assessors Map& Parcel Numbers
Sl Il06e ' iz+
1.la Is this an accepted street'?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District 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.O.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❑
SE'CTION2; PROP.ERTY'oWNERStrip.
2. wnert ecord:
Name ri a6 �ti ;fla
Stnt) City, b« sT
o.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKt(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupie ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ er of Units_ Other ❑ Specify:
Brief Description of Proposed Work 2: 012ia&LQ h
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only.
Labor and Materials
I Building S 1. Building Permit Fee:S Indicate how fee is determined:
2. Electrical ❑:Standacd._City/TownApplicationFee
S ❑'rotal Project Cost(Item 6),c multiplier x
3. Plumbing S 2. tither Fees: $
I. M-chanical (IIVAC) S List:
i. :%lechanical (Fire
Snp tressiun) _ Total All Fees: .S_
Check No, Check Amount: Caah \nlumit.
�
Total I'toiect Oust: S Q
C/ ❑ I ud ut Pill ❑ Outstandin- Ralance I)u�
SECTION 5: CONSTRUCTION SERVICES
5A Cmtstrueliott Supervisor License(CSL)
License Number _---- E.epiratiou Date
Name of CSL I folder List CSL'Type(see below)
rype - Description
No. and Street
lJ Unrestricted (Buildings up to 35,000 cu. tt.
JD
Restricted 1&2 Famil Dwelling
Cityirown, State, ZIP Roofin Covering
Window and SidinSolid Fuel Burning Appliances
bisulauon1'ela hone Email address Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
I IIC Company Name or IIIC 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 7a: 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's Name(Electronic Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, [ hereby attest under the pains and penalties of perjury that all of the information
Zcontau
' Ed in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized A�cnt's Name(Electronic Signature) ue
NOTES:
I. An Owner who obtains a building permit to do hisiher own work,or an owner who hires an unregistered contractor
(nut registered in the Houle Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty find under M.G.L. c. 142A. Other important information on the H[C Program can be found at
www.nrus.,-ov.oca Information on the Construction Supervisor License can be found at t%%v .utass.-gov dL
2. When substantial work is planned, provide the information below:
Tord floor area(sq. ft.) (including garage, finished basemenVattics,decks or porch)
(dross living area (sy. it __ _ Ifabitable room Count _
Nmnberoftirglaces_---_---_— `'umber ofbedrootrts _-_--
Number of bathroom; Number of halG'b;ulu _ —"—_--- —_
fvpo of heating ;y,tem Number of decks,'pnrd es
peorcoolingw�lent Fuclosal __. (lpcn
1 fnl it I'r .'tI
' q u u F rnrt t, a e` rty [it:[it: nb;utut .I toi 'I� IJI I'iujcet
I
CITY OF S-U-Em
PUBLIC PROPERTY
DEPARTI[ENT
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ra.f-S.71195" f FAA 075.71496e
HOMEOWNER LICLNSE EXliMM0,•4
Pkwe "I -
Data 3
Lob La,do. 6 lllibe2 s�
Home Owner Address l a c
Hon@ Owner Telephone &2A - -
Ptesd Mailing Address; a
The csureat exemption of"Homeownars"was extended to inehade owner-occupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
him who dos not possess a licenso provided that the owner sets as supoevisor,
DEFINMON OF HOMEOWNER
Parsoo(s) who own@ s parcel of Lod on which hdshe resides or intends to raids, on
which there ie, or is intended to be, a one or two s9umily dweWng; attached or detached
snvctttra accessory to such use and/or lbrm structurm 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 OQleisl, on a form acceptable to the Building
OPllcial, that halshe be responsible for all such work performed under the Building
Permit.
The undenigrted "homeowner"aantmes responsibility for compliance with the State
Building Code and other applicable by64aws and regulations.
The undersigned "llcmeownes"certifies that he/she undentands the City of Salem
Building Department minimum i7-7�;
ion procedures and requirements and that hel e
Will comply with said proceduresequirements
HOMEOWNERS SIGYATML,"
APPROVAL OF 9UILD .VG LVSPECTOR
See other side for state code
I
Sur'
CITY OF SALZNf, tiLUSACHUSETI'S
2 t� ; �1, •' Bt LD4YG DEP.ia-n ErT
120 SHL`7GTON STREET, 3W FLOOR
TEL. (978) 745-9595
KiatDERtEY DRiSCOLL FAX(978) 7-W-9346
NLkYOlt THON,ES ST.PIERRS
DIRECTOR Of PL13LIC PROPERTY/BE:aDLYG CONL\tt5SEOtiER
Construction Debris Disposal Aftldavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 ChfR section l 11.5
Dcbris, and the provisions of tMGL c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
111 work shall be disposed of in a properly licensed waste disposal facility as defined by jWGL c
ti 1, S ISOA.
111e debris will be trinsported by:
—T-
1 1 GE IZ
(Iianlc af hauler)
The debris wil
l be disposed of in
(nanlc of racility) _
(Adres.s Of facility)
signatur ofpa'ntitappli�ant
d.11e