3 SPRINGSIDE AVE - BUILDING INSPECTION �
� The Commonwealth of Massachuse[ts
=y�y Board of Building Regulations and Standards Town of
O �G�,� Massachusetts State Building Code, 780 CMR, 7ih edition guildi�
� Building Permit Application To Construct, Repair, Renovate Or Demolish a t�
� O�re-or mily Dwe!/ing �
his Sectio r Ofticial Use Only
Building Permit Number. ' Date Applied � � 0
/
Signamre: ��` � ' ���
Building C mmissioned Inspecror of Buildings Dare
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
`� SP+�,� �s,Zc h ��
1.t a Is this an accepted street?yes_�/ no Map Number Parcel Number
1J Zoning tn(ormation: L4 Property Dimensions:
Zoning Dis[rict Proposed Use Lot Area(sq R) Fron[age(R)
1.5 Building Setbacks(R)
Fron[Yard Side Yards Aear Yard
Required Provided Required Provided Required Provided
1.6 Wate Supply:(M.G.L c.40,§54) 1.7 Flood Zone[nformation• 1.S Sewage 9i"sposal System:
Public� Priva[e ❑ Zone: _ Outside Flood Z • e? Municipal'� On site disposal system ❑
Check if yes
SECTION 2: PROPERTY OWNERSHIP�
2.t Owner�ofRecord: � S�r\w�S( I� � � �w\
� 4.J^�2 ��
Name(P t Address for Service:
..� �P78 — 7 ��/—�9.S�I
Signatu Telep one
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Altera[ion(s) ❑ Addition �
Demolition O Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Descrip[ion of Proposed Work�: , N� C �'
SECTIOIV 4: ESTiMATED CONSTRUCTION COSTS
Item Estimated Costs: Ofticial Use Ouly
Labor and Materials
I. Building $ I. Building Permit Fee: $ Indicate how fee is detetmined:
❑Standazd CityITown Application Fee
2. Electrical $ !� ❑Total Project Cost�(Item 6)x multiplier x -
3. Plumbing 5 / 2. Other Fees: $
4. Mechanical (HVAC) $ �— Llsc
5. Mechanical (Fire �
Su ression �� To[al All Fees: $
� Check No. Check Amount Cash Amount:
� 6. To[al Project CosC � ❑ paid in Puil ❑ Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES ,
5.1 Licensed Construction Supervisor(CSL)
�� �,,�N e2 License Number Expiration Date
Narqe of CSL- Hplder � List CSL Type(sec bclow)
�
T Descn tion
Addrcss U Unrestricred(u ro 35,000 Cu. Ft)
- R Restricred I&2 Famil Dwellin
Signamre M Mason Onl �
RC Residential Roofin Coverin
Telephone WS Residential WindowandSidin
SF Residential Solid Fuel Bumin A liance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(H1C)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURAIVCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted wi[h this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building pertnit.
Signed AfTidavit Attached? Yes .......... ❑ No........... O �
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 ro work authorized by this building permit application.
Si nature of Owner Dace
SECTION 76: OWIVER� OR AUTHORIZED AGENT DECLARATION
I� ,as Owner or Authorized Agent hereby declare
that the statements and infortnation on the foregoing application are We and accurate,ro the best of my knowledge and
behalf.
Print Name , �
Signature of Owner or Authorized Agent Date �
Si ned under the ains and enalties of er u
NOTES:
1. An Owner who obtains a building pertnit to do his/her own work,or an owner who hires an unregistered wntractor
(not registered in the Home Improvement Con[racror(HIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important infortnation on the HIC Program and
Construction Supervisor Licensing(CSL)can be (ound in 780 CMR Regulations I I O.R6 and I IO.RS, respectively.
2. When substantial work is planned,provide the information below:
Total Floors area(Sq. PtJ (including garage, finished basemendattics,decks or porch)
Gross living area(Sq. FtJ Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type af cooling system Enclosed Open •
3. "Total Project Square Footage"may be substitu[ed for"Total Project Cost"
� _
CITY OF S.�LE.�i
PUBLIC PROPERTY
DEPAR'T�iENT
iu,aritsr^•,�•••��
�� � 130�i/wwtro[r1oN Sn�T�SuFx�fwsu0a'seRS 019'0 �
7�1:9'.'F735-9S9S� Fn%.97L7d0.961�
HOi�1EOVWER LICENSE EXE.v[PTION
piew Prist
Date l � ���
Job Lotatio0 ,�, � �T��wci � e �P �vP� ��A-�F_�
Homa Ownea Address—�A v�
Home Ovvnar Telephone�fZ 7 �/�F K4<"�
Pre�aat Mailin�Addt�w S��=-�
The cuirent exempdon of"Homeowners"was entended W i�lude ownc-occupied
dwellings of two Uni4 or les�and w atlow such homeowners to engage an individual for
hire who.doa not poasav s license.Pt'uvided that the own�acta ar auperviaor.
DEFIlVITION OF HOMEOWNER
person(r) who owni a parcal of land on whic6 hdshe reaida or intend� to resid0. on
whic6 there ie, or is intended w be, s one or two family dwelling. attached or detached.
suucnua accessory to such use and/or Fazm structura. A penon who conshvcta moro
thaa one home in a two year period shaU not ba coneidered a homeownu. Such
"homeownd'shall submit W tfu Building Ot�icial, on a fortn acceptable to the Bnilding
OtTicial, that hdshe be responsible for all such work performed under the Building
Pertnit
The undmigned "homeownd'assumd responsibiliry for compliance with the State
Building Code and other applicable by-lawa and regulations.
The undmigned "homeownd'certifia that hdshe understands the City of Salem
Building DryaRment minimum inspation procedurea and requiremcnt� and that hdshe
wiU comply with said procedura and req iremrnts.
HO�tEOWYERS SIGNAT[,'RE �--G�
APPROVAL OF BUILDING LtiSP OR
� See othzr side for state code
,; CITY (�F SALL.M
• '��-�` /'� PtBL1C, PRc�PRERTY
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� ('onstrurtion Dcbris Disposal .atiidavit
(rryuirr� fi�r �II �cnwliti��n :uiJ rrnu�:itiun ��ork)
In ac�urJ�ncc ��itl� th� sixlh �Jition of lhc Statc [3uil�ing Code, 750 Ch1R s�ctiun I I 1 �
D�bris. and the pro� isiuns uf'�iGL c �0, S 54;
puilding I'ermit � is issucd with the conditiun that the dcbris resullin� tiom
this ��urk sh:ill hc di,p��scd uf in u pruprrly liccnscd �va,te �lisposal lacility as dctincd by MCiL c
1 I l. S I SI�A.
Thc dchris �+'ill I�C lraniportCd by:
lV�dHn t.vl P ( G/� ti-s
U�amc ut haul�r) �
l hc �lcbris will bc dis�wsed of'in :
(n�me ul I�cihly) .
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