12 WILLOW AVE - BUILDING INSPECTION l
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY� M,. Massachusetts State Building Code, 780 CMR S
Revised
Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This"Section For Official Use Only
Building,Permit Number: I D Applied:' "
Building Official(Print Name): - Signature Date
SECTION 1:SITE INFORMATION
L1 P o erty Address: 1.2 Assessors Map&Parcel Numbers
f / ,//acii/e /en ,�A '2/97d
I.la 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 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 a 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 yes[]
SECT[ON2: PROPERTY OWNERSHIP"
X2.1 Owner of Record:
"KIP=(Print) City,State,ZIP
// lj, //oc, /9z 7k/-zn-3.3-y it 2�/�Cro/Coh-r
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
X
SECTION4: ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs:
Official Use Only
Labor and Materials -
1. Building $ I. Building Permit Fee:$ Indicate how fee is determined:
❑.Standard City/Tow nApplicationFee:.
2. Electrical $ ❑Total Project Costs(Item 6)1.x multiplies x
3. Plumbing $ 2. Other Fees: $ x
—
4. Mechanical (14VAC) $ List: . �� � (�
5. Mechanical (Fire $
Suppression) Total AllFees:S
Check No. Check Amount: Cash Amount:
�i 6. Total Project Cost: $ IM 0 Paid in Full ❑Outstanding Balance Due:
r i
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Ifolder
List CSL Type(see below)
No.and Street Type - Description
U Unrestricted(Buildings tip to 35,000 cu. ft.
R Restricted 1&2 Family Dwelling
Cityfrown,State,ZIP M Nfasonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Teic hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
I-IIC Company Name or HIC Registrant Name
No. and Street Email address
City/Town, State,ZIP 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
t4 act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNERt 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 understanding.
odCl
Print Osoner's or Authorized Agent's Name(Electronic Signature) � Date
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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 NI.G.L.c. I42A.Other important information on the HIC Program can be found at
www.mass.eov.oca Information on the Construction Supervisor License can be found at w�a%v.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. 11.) 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 syslern Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost'
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CITY OF sm-Em
PUBLIC PROPERTY
DEPARTMENT
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HO��tEOWNER LICLNSB E.XE.M"101*4
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Date
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Rom Owner Addresd /7 c.,I/,), >n� dyl�✓J 9�,1
Home Owner Telephone 74
Ptesed Moilia l Address i-? t,,I d f., n t j-o
no current exemption of"Homeowners"was extended to include*wow-occupied
dwsulnv of two Units or fees and to allow,ruck homeowners to engsp an individual for
him who does one possess a ucmM provided that the owner acts as supervisor.
DEFENMON Of HOMEOWNEII
person(s) who owns a parcel o(W W on which hdshe rssida@ or Intends to reside. on
which then is, or is Intended to be,a one or two family dwoftg, attached or detached
ttrucmrres accessory to such use and/or farm strueturm A pawn who construct@ more
than one home in a two year perlod.&hall not be considered a homeowner. Such
"homeowner"shall submit to the Building Oillcial,on a fond acceptable to the Building
Oillciak that he/she be responaiblo for all vxh work performed under the Building
Permit
The undersigned "homeowner"assume$responsibility for compliance with the State
Building Code and other applicable by-laws and regWadon&
no undenigned "homeowner'certifte$ that hdshe undentands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
.'rill comply with laid procedures and r u' eau
HOMEOW`IERSSIGNATL'RE
.APPROVAL OF 91VILONG 0;SPECTOR
See other tide far state code