65 VALLEY ST - BUILDING INSPECTION al
The Commonwealth of Massachus
etts
t� Board of Building Regulations and Standards Town of
�y Massachusetts State Building Code, 780 CMR, 7'"edition Wilbraham
(� Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a 413-596-2800
One- or Tito-Fandly Duelling Ext 118
This Section For Official Use Only
Building Permit mber. Date Applied: it. 3 -0 6
Signature: � � • QCU
Building Commissioner/Inspector of Buildings Date T I
SECTION 1: SITE INFORMATION
I.//I Pror� /rrl��� Address: L 1.2 Assessors Map& Parcel Numbers
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dime,isiens:
?i
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.I,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check if yes[] Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
.1 Owner'of Record: / /<_ ('
5-CC /I f74-�G 1�/ fJ.J f/a�IC`-i J t- ✓>4< rM a d
Name(Print) Address for Service:
r.�vf 9'38—Y}9—9J/2
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
nef Description of Proposed Work':_ �tS4nlla t..n.� o J` a �a 1l�4 S vo__ A
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 1. Building Permit Fee: $m_Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $
❑Total Project Cost(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire
Sup ression) S Total All Fees:$
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ �QUU % Paid in Full 0 Outstanding Balance Due:
r`
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Dale
Name of CSL- Holder List CSL Type(see below)
T Description
Address U Unrestricted(up to 35,000 Cu. FtJ
R Restricted 1&2 Family Dwelling
Signature M Masonry 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 Affidavit Attached? Yes .......... ❑ No ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 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.
Signature of Owner Date
SECTION 7b: OWNERI OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that t e statements and informati the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
4/�
Signature of Owner or Authorized Agemf`J Date
Si ned under the pains and penalties of edu
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 110.R5, 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 SALEN1
PUBLIC PROPERTY
DEPARTMENT
u+aarsr^-w' L
NAVM 130 WASWACKM MM 0 SA aK NAtMACKLscM 01970
TEL 976.7354S"• FA).9711-740.9646
HOMEOWNER LICENSE EXE.MMON
Pleau Print
Date //-3-c) s' _
Job Location
Home Owner Address 6 r i 01 F')-
Home Owner Telephone_'F a2d- Y
Present Mailing Address_ & s ✓i/
The current exemption of"Homeowners"was extended to include owner-=upied
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 there 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 forth 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
APPROVAL OF BUILDING INSPECTOR
See other side for state code
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a^ B�tijFfout'e$t�,Kn�tatg � "
� �+f;' npu� #"�"q YlbsfG�e ��dt�y �Bt+6wsr�>��-ErnisSlnn�s
28-7/16 32-5-16 29-1/16 425 up to y 14,620 1.7 to 7 81 220 EPA
3,300 to 60,200 compliant
23-1/4 26-7/16 22-15/16 258 j p to [0 2,9000 1.5 to 4 40 160 .7
28-1/2 31-5/8 27-5/8 349 up to 17,200 2.0 to 5.5 80 160 .9
2,350 to 47,300
25-7/16 27-3/4 21-3/16 240 up to 12,900 1.5 to 4 52 160 .7
�ze�siaWwce) 1,475 to 34,400
CLEARANCES
Mt.Vernon AE }dam') o A- Back Wall to Appliance......................2" ALCOVE INSTALLATION FLOOR
B Side Wall to Appliance......................W Min Alcove Height...............
43" PROTECTION
Comer Installation: Min Alcove Side Wall.............6"
C Wallto Appliance..............................2" Min Alcove Width................40" I............2" a•
With Top Vent Kit: Max Alcove Depth...............36" !. 2"
D Back Wall Flue Pipe.......................3" K...........6"
E Side Wall too Cast Top........................6" l ® l
F Back Wall to Appliance......................8" CORNER HEARTH PAD SIZE
Corner with Top Vent Kit: 38-3/4"w x 38-3/4"d IK
Advanced Energy G Walls to Appliance............................3" Use a noncombustible floor
protector,extending beneath
Castile A Back Wall to Appliance......................2" heater and to the front/sides/
B Side Wall to Cast To 6" ALCOVE INSTALLATION rear as indicated.Measure
p"""""""""""' Min Alcove Height...............43" front distance(K)from the
e C Corner Install Walls to Appliance.......2"
With Vertical 3".6"Adapter Kit Installed Min Alcove Side Wall.............6 surface of the glass door.
o D Back Wall to Flue Pipe.......................3" Min Alcove Width................38"
F E Side Wall to Cast-Top 6" Max Alcove Depth...............36"
c: F Back Wall to Appliance..................:...8"
e G Corner Install'Walls to Appliance.......2" CORNER HEARTH PAD SIZE
Original Energy o H Corner Install Walls to Flue Pipe........3° 34-1/8"w x 34-1/8"d IMPORTANT I READ
9 9Y BEFORE YOU INSTALL!
Classic BayA Back Wall to Appliance......................2" ALCOVE INSTALLATION Refer to the Owner/Installation
PP Manual for complete clearance
1200 0 O B Side Wall to Appliance...................:..6" Min Alcove Height...............44" requirements and specifications.
C Corner Install Walls to Appliance 2" Min Alcove Side Wall.............6"
a ® PP
With Vertical Adapter Kit Min Alcove Width.........40. The images and descriptions in
1/2" this brochure are provided to
D Back Wall to Flue Pipe......................3" Max Alcove Depth...............36"
E Side Wall to Appliance......................6" assist you in product selection
IFBack Wall to Appliance................7-112" only.
® e �0 G Corner Install Walls to Appliance.......2" CORNER HEARTH PAD SIZE 'Heating capacity(in square feet)is
40-5/8"w x 40-5/8"d guideline only and may differ slightly
due to climate,building construction
and dition,amount and
of
Original Energy - insulation,Vocation of the heate
r,
air movement in the room.Based an
A Back Wall toA Nance 2° maximum square feet of Energy Star
Santa Fe ,r�ir ! PP ALCOVE INSTALLATION equivalent home with Bors In heating
B Side Wall to Cast Top ..6" Min Alcove Heigh ...............43° andequivalent
framed Insulated floors ceilings
heating
v I C Corner Install Walls to Appliance ..2" Min Alcove Side Wall.............6" zone 1.
With Vertical 3"-6"Adapter Kit Installed Min Alcove Width................38"
*See Owner's Manual for exceptions.
" D Back Wall to Flue Pipe.......................3" .Max Alcove Depth...............36" ••gm/Hour Input calculated using
E Side WalIto Cast Top........................6" premium wood pellets at 8,600 Btu/lb.
r " F Back Wall to Appliance......................7" Btu output will vary,depending on the
-"'•- G Corner Install Walls to Appliance.......2" CORNER HEARTH PAD SIZE brand ffuel used.For best results,
Original H Corner Install Walls to Flue Pipe........3" 38-7/8"w x38-7/8"d consult your authorized Quadra-Fire
Energy
seLmtFiv 51g tlfr tr'}j 2pphance
Warm Traditions Stove Shoppe QIlEIDQF/' /RE
144 Pine Street
Danvers
�r,.MA 01923 Visit our Web site arwww.quadrafire.com
978-77/—5562 Quadra-Fire is a registered trademark of Hearth&Home Technologies.Product specifications and
U pricing subject to change without notice. All Quadra-Fire pellet appliances shown are tested and
listed with OMNI-Test Laboratories,Inc.,of Beaverton,Oregon to ASTM El509,ULC S627-00 and
ULC/ORD-Cl482 Room Heater Pellet Fuel Burning Type(UM)84-HUD.Suitable for use In mobile
homes.These.products are covered by US Patents Nos.5000100 and 5582117 and other patents
pending.
Product specifications and pricing subject to change without notice.
QDF-1014U-0508