6 SOUTHWICK ST - BUILDING INSPECTION (4) 0 The Conunon%scalth of NIJSSJchusettS
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Board of Building Regulations and Standards \II NIl lPt\I fl 1
t ; MaSeachLISMS Stale 13 ill lding Code. 7SU ('N1R. 7°i edition
I 'SI-.
13itiIding PeflitIt .Application To('oilstruct. Repair. Reno%ate 0r I)emoIisIt a Rrl
One- rrr Tiro-1 iurrilr Dnt'llilig
—i
This Section For Official Use Only
1
Molding Pan11" N' rc ate :\pplie`J�: /--
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Building Crnunl.a •i/ Inspecnm, uJdnlgs U.ur
SECTION 1: SITE INFORMLA'1'ION
Ll Property %ddress: 1.2 Assessors slap & Parcel Numbers
Sfreef/ ----- -
I.1:t Is this an accepted street') 1es ✓ IN, Map Nnlilher P:uicl Nuwher —
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed I�Le L AiArea l+q tit Flowage Ito
1.5 Bottling Setbaiks (fe) —
j Front Yard Side Yards Rear Yard I
I Required Proe ided Requoed Pnwlded Required Piu.iJrJ
_ 1
1.6 Water Supply: (M.G.L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal S)stem:
Zone: _ Outside Flood Zone'! Munici al ❑ On ,ite dis osal s smin ❑
Public ❑ Pri%ate ❑ Check if yes❑ P I }
SECTION 2: PROPERTY OWNERSHIP'
21 Owner'of Record:
_Jq e4 Moon e G e ougl , e h S4-
-
N.w iPrino Address for Service:
Slgnl to Telephone
FI SECTION 3i DESCRI.PTION OF PROPOSED WORK (cheek all that apply)
New r'oostrultinn ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteruinnls) ❑ Additi�m ❑ I
Demolition ❑ Accessory Bide. ❑ Number of Units Other ❑ Specify: _
Brief Description of Proposed Work': ---
__ ysj-nll �e I� 2j{ S cove (-o y-P(D�a P PXtsfr lv9 t.uad ove.
cECTION 4: FSTIMATED CONSTRUCTION COSTS
W
stimated Costs: Official Lse Only
IL.ahurand Materi;dsting 5 I. Building Permit Fee: $ Indicate him tee a determined:
❑ Standard City/TownApplication Fee
ical 5 ,❑Total Project Gtst (Item Gl s multipliering $ 2. Other Fees: 5nical IHVAC) $ List:�100nical (Fire ion) Total :\II Fees: 5Check No. Check :\mount ('.uh :\m„ant Ptvrjec[ Cost S e21PO ❑ Paid in Full 0 Outstanding Bal nee Due
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSI.)
Llemne .V unlhs F.spu.luoll O.ua
r
Name of CSL Holder ,.
List C'SI_ fspe na• hrlow 1
\dares, I's e Descn lUn
o
lI I'niestocted into 15.WO Uu. FI
-- — R Resumed I.\;_' F.muh Dwcllme
Slgn;uurc \I \I;uonn Only _
RC Resdenual Roolinc Coseun� _�
felrphune \\s, Rcadcwlal \'t lido.. .md SiJui_
SF Rcsldollial Solid Pucl liwiuii__ \pl+li.in.r 11IN1.1l l.nnei !
D RLjcllu.l Uanwtiunn --- .-
5.2 Registered (tome Improiernent Contractor 0110
IiIC C•oulpany Name or HIC Registrant Name Reglsruuun Numher
Address
F.ynruuon Date
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 25C(61)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure it, pn,ude
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, J pyneS (roNe as Owner of the subject property hereby
authorize to act on my hehadf. in all nlatt%,is
relative to won k authorized by this building permit application. -
Si na re of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
(hat the statements and information on the foregoing application are true and accurate. to the best of my knowledge and
behalf.
kSirgnatureot
Name
Owner or Authorized Agent Date
ed under fife mns and enahirs of rruNOTES:
An Owner who obtains a building permit to do his/her own work.or anowner who hiresan unregistered :onrrasnnnot registered in the Home Improvement Contractor(HIC) Program), will not hasr access to me au hill:uiml j
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 CNIR Regulations 110.RG and I I0.R5, re,peclocly
' When substantial work is planned, provide the information below
Total flours area!Sq. R.1
(including garage. finished basemen Jades. decks or purch,
Gross living area ISy. Ft.) Habitable room count
Number of lueplaces Number of hedroums
Number of hathruums Number of half/halhs _--
fcpe of heating system _. _-- Number III deck,/ pl,rehcs -_-
Type ul cooling system _ ElMo,edl
1. "Total Project Square Footage" may be xlbstituted fir 'fatal Project Co,I"
CITY OF SALE.M
PUBLIC PROPERTY
DEPARTMENT
IU�O�L�K,tl-tY�
NAVM 1311 WADONGrON S'MKW•SALA4 NASMACHUNM 01970
TM 9'1-745-9S" 9 FAs 978-74&984
HOMEOWNER LICENSE EXE.MMON
please trfat
Date -ate-or
Job Location 4 5ov4eW 4 ;t
Home Owner Address A aue. Solbw Mo
Horne Owner Telapbone
Present Mailing Address_ as 0,-Ac t_ 1Av� S afev: . ma
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.
DEFINMON OF HOMEOWNER
Persons) who owns a parcel of land on which he/she resides or intends to reside. on
which them 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 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 CtSPECTOR
See other side for state code