32 WEST AVE - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
Wilbraham
Massachusetts State Building Code, 780 CMR, 7"edition
Building Dept
e� Building Permit Application To Construct, Repair, Renovate Or Demolish a 413-596-2800
^+ , One- or Two-Family Dwelling Ext 118
This Section For Official Use Only
Building Permit Number: Date Applied: r - 0 Zp
Signature: /d' Y
Buildi Commissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
I.I Pro erty Address: l� - 1.2 Assessors Map& Parcel Numbers
v-�_ _ _
I.1_a Is this an accepted street?yes—� no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) 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,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
.1 wner'of Record:
P, OacT Aug
a e(Print) Address for Service:
1� 7g� ESs3 05l-7�
pa re Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ 1 Existing Building Owner-Occupied ❑ 1 Repairs(s) K I Afteration(s) ❑ Addition ❑
emoiition ❑ Accessory Bldg. ❑ Number of Units4 Other ❑ Specify:
Brief Description of Proposed Work': A/k — G 00 l YL f Hil Cr /) Yt *'!
17C1ti- CWKhln.6 .1�_1 00_g,,__
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $ J�/�
4. Mechanical (HVAC) $ List: - /` ( 6
5. Mechanical (Fire $
Suppression) Total All Fees: $
/ _ Check No. Check Amount: Cash Amount:
/ 6. Total Project Cost: $ M ``
490 • 0Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL-Holder
Lis[CSL Type(see below)
Address Type Description
U Unrestricted(up to 35,000 Cu. FtJ
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC Residential Roofin Coverin
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
I, as Owner of the subject property hereby
authorize._ to act on my behalf, in all matters
relative to work a thorized by t ' building permit.application.
SignaA r of OwnerDate
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
I,_ ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Frint Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury
NOTES:
1. 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 I O.R6 and I IO.RS, respectively.
2. When substantial work is planned,provide the information below:
Total Flours 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"
r ,
CITY OF SALEM
'jam y IP j PUBLIC PROPRERTY
DEPARTMENT
' +verse
..I ,. I_; U � .i m:..:,...1:!Ilfs �i� l �t. \I i•.is ..1 . - �'' -
construction Debris Disposal Allidavit
(rek1twed li)r ill demolition :uid renuratiun work)
In accurdance i\ith the sixth edition of the State Building Code, 780 C'h1R section 111.5
Debris, and the: provisions of',1GL e 40, S 54;
Building Permit if is issued with the condition that the debris resulting from this work shall he disposed of in a pruperly licensed waste disposal facility as defined by MGL c r
I 11. S 150A. i
The debris will be transported by: m'
1 name tit liauler)
I he debris will be dispo
sed of in
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CITY OF $ALEM
PUBLIC PROPERTY
DEPARTMENT
IV�O{!� LY NIVYY 1
130 WAgW4MM STIMN•Su Ex NwSIAMSUMS 019'0
TEL 97.11-70.9S95 # Ftx 978.74&96N
HOMEOWNER LICENSE EXEMPTION
Please Print
Date
Job Location )JR W ES T j9 v C
Home OwnCr Address of 4 y H=G-H S T
Home Owner Telephone 9`7 k JrS ;50 4`7 a
Present Mailing Address
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.
DEFINITION 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 form acceptable to the Building
Official, that hdshe 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 proved ea and requirements andthat he/she
will comply with said procedures and uiremen .
HO.IEOWNERS SIGNATURE
APPROVAL OF BUILDING IINSP OR
See other side for state code