20 SOUTHWICK ST - BUILDING INSPECTION (2) q 1 --- I'he C•onnnollwcahh of blassaclnuclts
Ilu;trd of Iluilding Reguhttions and Standards Cl I'1'OF
J s kfassaehusc(ts Statc Building
g CuJc, 780('MR
L.,,..
Building Permit hpplicniutt 'fo Construct. Repair. Renovate Or Oct ulish kvri,rd IIw• 'Ill
OwerTurt-fiuudt U,rr/11n•11
This Srclion Fur Otii I Use Onl
Building Permit Number: U Jc Applied; /
Iluilding Official(Print Nmnc) J
Signature Uatc
SECTION I:SITE INFORAIATION
L I Property AJdrar.w — ) 1.1 Assessurs blep di Parcel Numbers
I.la Is this an lace led street? •a no 11ap Number I'urcel Number
1.3 Zoning Information; 1.4 Property Dimensions;
TuningT fining Djstr(c, I'mpnsed tjv --_
Lut Aren f sy III 1.,1 Bullding Setbacks(R) Fmnlugu(Il)
Front Yard Sidu Yards
Roar Yard
Required Provided Required Provided
Required Provided
1.6 Water Supply:(M.G.1.e. qU. §sq) 1.7 Flood Zone Informallon; 1.3 Sewege Disposal System:
Ih,blie❑ Private❑ Zone: _ Outside Flood Zone?
Chuck if es❑ Municipal❑ On site disposal s)slu,n ❑
SECTION It PROPERTYOWNERSHIP$
2.1 Ownerr of Record;
Nana(rrm► rt
C,1)',Slala,TIP
relephune ;',nail Address
SECTION!: DESCRIPTION OF PROPOSED WORKs(check ell that apply)
New Construction❑ E.%isling Building❑ Owner•Occupied ❑ Repairs(s) ❑ Afteratlon(s) ❑ Addition
Demolition ❑ Accessary Bldg.❑ Number of Units
Brie fDescriplionof Proposed \Vork': Other ❑ .Specify:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
lieu, Estimated Costs:
(Lahur and\Luerials) Official Use Only
1. Building S I. Building Permit Fee; S Indicate how fee is determined:
-'. Ff"Ificaf S ❑Standard 0y!Tuwn Application Fee
I 1'lunihing S ❑Tulnl Pruject Cost l Item 6)..1 multiplier
'. Other Fees: S_ -- -
J. \Icch.mic.d ill\ \('1 $ List:
S 1lrchanical :Fire _
1 Cu nr�siunl S romi \it Ferf: S ._. .._ .
I'utul I'r,ject CmNI: S 000 C hccA No. _. _( hvck Ailiuunl:
v—`� O RiiJ in Full Uulstauding 11ai•mcc Due:
r >
St:("PIONS: ('1)Ntil'RU("rION SF.K%I('ES
S.I ('onstructiun Supvnisur Lfccnse(C'SLI - ._ .. j:.iir;uinn IAue
I icellw Numher I
Piao
Dcscripliun
weer ` tl I htnstricteJ IlludJiu y li Iu tt,Ullll ca ll.l
V A p ��=11�-- R I1c,tricleJ IR?P.unil Daellin
".�=�- \I 1laion
Cinil'oen,Slate,/II' NC N,M,lin Cowrin
µg µ'indmr.mJ SiJiu
— SF sulid fuel Ilurning Appliances
I Insululiun
-fete hone
fnlailaddres D Denu,liliun
4.2 Registered Ilume Improvement Cuntroclor(IIIC) if fl IGl-5-- R- t --
L �L �l_ IIICIpC ltcglsl tthet li\ltirilliou Dole
II (II (UInpJ�Il( ItegITlrJIIINJIIW ,..�—
�a` i.JU l s� limuilaJJress
Nu�:u1J slues ��. O LCi'10 �l'7 Ply`'l
"—`— rek hone
cityrrowfl.state ZIP 2!C(6))
SECTION 61 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e. is].1
be mpleted and submitted with this application- Failure to provide
Workers Compensation Insurance affidavit must
this affidavit will result in the denial or the tssu of the building permit.
Signed Affidavit Attached? Yes..........
No...........O
SECTION 7e:OWNER AUTHORIZATION TO BE COM1IPLETED 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.
Date
Print Ueoer's Nwne(ENctrunic Signulum)
'SECTION 7b:OWNERI 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 understand, g. 21
l Date
1-6 it Oener's or AulhurveJ,\µnl s 4ultlu 11.14,trume`Inn uueel ,
NO'FL31
. nr ` v hires an unregistered tncur
nvtul lion
I obl orI ICProgram), illwhaeaccesstothearbir
�nutrogisterediheHomehpruenrntCurcn on the to
prog`amlur guar?°tyl ulld utUun on he ConstructionfA. t Supers oar t i furniuse can be fo�d��C Prugra n e,n`bal'bwiJ at
lien substantial twrk is planned, pro, the inl'uI ita11 inglo g�1"se. finished basement attics.deeks or porehI
rota) dour area I+y 11.1 _ ---- Habitable rouni count _.. . . .
pros; li\wq area 1 sq, ll.l ..... �uuther oI heJruums
I
♦tutlherol'Iircplaecs _ --- \unlbcrol'hallhalils
I ♦onlheralhathrounls Vunthcrol'Jeeks, parches
I'.pe a(he,uutg s„leut (tl,cn
I'nclo,cJ
1 f+aul 14„jcet equar¢Footage" in,n be ,uh,unue.l her..ro6d I'n�jeet Co,i'
4
CITY OF SALE.M. NWSACHUSETTS
Butt mG DEPARTNaNT
N 130 WASHIINGTON STREET, 3" FLOOR
TEL (978) 745-9595
F.Ax(978) 740-9846
fCi\{BERi-EY DRISCOLL
MAYOR Tliomu ST.PtERn
DIRECTOR OF PUBLIC PROPERTY/BUIMNG COINIS5IONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section It 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
�The
debris will be disposed of in
(name of racility)
(address of facility)
signature of permit applicant
,late
4cbnsal(dac
CITY OF S.UY. Nf
PUBLIC PROPERTY
DEPARTMENT
o,w�,ar ournu
wYOa 133 WAssmaro 1 snum•uLm x&uAowscm ai oars
m+-s.n+sssss•K..s 9?0.7+o•9646
HOMEOWNER LICLNSB EXE.MMON
NNW Error
Job Loeatiae
Home owner Address
Home Owoar Telephone — -
Presmt Mailing AddrM — w Ctc
The current exemption of"Homaownere was extended to include ownar-occupied
dwellings of two Unite or tee and to allow such homeowners to engage an individual for
hire wbo don not posses a license,provided that the owner act@ a supervisor.
DERNMON OF HOMEOWNEA
Penom(a)who owns a parcel of Lod on which he/she raids@ or intends to resider on
which that is, or is intended to be,a one or two fha*dwelUng, attached or detached
structures accessory to such use and/or farm structures. A person who construct@ more
than one home in a two year period shall not be considered a homeowner. Such
"homeownee shell submit to the Building Official,on a form acceptable to the Building
Oi'Acial, 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 bylaws and regulations.
The undersigned "homeowner'certify that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
.vill comply with said procedures 7turemenM
HOMEOWNERS SIGNATURE
APPROVAL OF HUILDNG NSPECTOR —
See other side for state code