12 SUNSET RD - BUILDING INSPECTION A W/
' The Commonwealth of Massachusetts
�y Board of Building Regulations and Standards Town of
y Massachusetts State Building Code, 780 CMR, 71h edition Wilbraham
Building Dept
Building Permit Application To Const , epal , t novate Or Demolish a 413-596-2800
One-or T -Family Dwelling Ext 118
Thi Section Fot qMcial Us Only
Building Permit mber: D p ed:
Signature:
Building Commissi er/Inspector o Buildi s Date
SEC N TE INFORMATION
Ll Property Addre 1 1.2 Assessors Map& Parcel Numbers
l.la Is this an accepted street?yeses no Map Number Parcel Number
11.3 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.G.L c.40,g54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
. Owner'of Record: /�//�
[may Vy3 e LT fO M ��`
a to Nn im
Name r- Address for Service:
� 978' - 594 - 4>37/
Signature Telephone '
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief//��Descriptionof Proposed Work': ' p&A A % '-t
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 7 p p6 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ s 000 ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ Op 2. Other Fees: $
4. Mechanical (HVAC) $ — List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
9 y Check No. Check Amount: Cash Amount:
00
6. Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
/ 1
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL-Holder List CSL Type(see below)
Address Type Description
U Unrestricted(up to 35,000 Cu. FL)
R Restricted 1&2 Family Dwelling
Signature M Mason Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature 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 Affidavii Attached? Yes .......... ❑ No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN .
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
authorize to act on my behalf, in all matters
relative to work authorized by this building petmit application. .
Signature of Owner Date
// SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I, L..xr r t,I De-,o-, ,r,&5 yk ,as Owner or Authorized Agent hereby declare
that the statem is and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf. 1 C(�� ,
hQN, oa—YSN I-SO!A.
Print e
09 s �_ ..,L /oA-16
Signature f Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
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 CMR Regulations I IO.R6 and I IO.RS,respectively.
2. When substantial work is planned,provide the information below:
Total Floors area(Sq. Ft.) (including garage,finished basement/attics, decks or porch)
Gross living area(Sq. Ft.) 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 of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
-
V.Wrot 130 WAsun[.�TMEET•S LEK VAMAOLL'SEM 019-0
TEL V;S-74S•9S"• F.4x 978-746-9846
HOMEOWNER LICENSE EXEMPTION
Please Print
Date o b 8 /
Job Location /� S a Z I+�n a�ndt S n l Q V^ xf 4
Home Owner Address /a S t,. .s e r Rd-alsgalir
Home Owner Telephone q 7 2, - -
Presaat Mailing Address /4- Sir.aeZ RnadlT SaL 112 M A
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
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on
which then 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 he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner"asstunes 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 rocedures and requirements and that he/she
will comply with said procedures and r i em
HOMEOWNERS SIGNATURE
APPROVAL OF BUILD[NG [INSPECTOR
See other side for state code
CITY OF SALEM
PUBLIC PROPRERTY
DEPAJtTMENT
r
construction Debris Disposal :affidavit
(required lix all demolition and renov:nion work)
In accordance \%itlt the sixth edition of the State Building Code, 780 Cb1R section I 1 1.5
bebris, and the provisions of MGL c 40, S 54;
is issued with the condition that the debris resulting from
Building Permit
this work shall he disposed of in a pruperly licenscd waste disposal I-acility as defined by MGL c
I 11. S 150A.
The debris will be trimspp-orrttcd by:
/�illQr �bNS ( ✓'vc ioh
(name (it hauler)
The debris will be disposed of in
;c� __Frckv.,s er
(name tit facility) I I 4
(aJdres.ur jnlily)
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