15 WILLOW AVE - BUILDING INSPECTION (4) it w � .
I The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
q Massachusetts State Building Code, 780 CMR, 7ih edition OF SALEM
O Revised Jarman
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 20014
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Nu er: Date Applied:
Signature: 52�z l-�
Building CommissioncOYInspector of Buildings Date
SECTION I:S001APORMATION
1.1 5 op� (rty i¢dress: 2 ssessors Map& Parcel Number
I 0 t�
1.1 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 fl) Frontage(d)
1.5 Building Setbacks(R)
From 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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP!
2.1 Owner'of Record: _
A�(Pri u� 1/� la s lc0.f TI s Address or Service;
�. �l(-7 `?
Name(Print)
l
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) ❑ 1 Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of units_ Other ❑ Specify:
Brief Description of Proposed Work': & ✓ t I a litu 0, q r e�-e va
lea Kd r ca.r .� traces r'o.i,..-�o
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OlMcial Use Only
Labor and Materials
I. Building s ys—&-io I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S O Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
a. Mechanical (HVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S /(�' ❑Paid in Full O Outstanding Balance Due:
�70
CK--4=� ���
r
. v 1
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) .{ lv+ i / 1—
License Number Expiration Date
NC 4.
Name of CS IIoIJer
A bo t ✓ - List C'SL'I'ype(see below)
1 I h
f Description
U Unresaricted(up to 35,000 Cu.Ft.)
R Restricted 182 Family Dwelling
Signature .rO g L� Y i M Mason Only
1. RC Residential Roaring C'overin
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
U Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) 1 a c f (19
a
III ' ompany Name or IIC Registrant Name ! Registration Number
t 2 c 07(e
J ss
'Q g �jo�(f/(2 Expiration Date
ature 'telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c. 152. 6 2SC(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...........O
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 71b:OW/NEW OR AUTHORIZED AGENT DECLARATION
IN�l �L�{� �, J..� ,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
alf. `L
�a
'_IN � C
Signature of Owner or Authorized Afgqt Date
(Signed under the nains and mnaltickvrperjury2
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 no(have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.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.
1. When substantial work is planned,provide the information below:
Total tloors 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"
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myself.(No workers'comp. c. IA L 1(4).and we hate no 12.0 Roof repairs
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In.urartce Company Name: -� 5 A
Policy e Or Self ina. Lie.V. i✓ Z (p 2-3i q Expiation Date:
Job Site Achim Giry/StaWZip:
.\clots a copy of The r.eAlen'compoesetMe Valley doclaratkte pop(skewing tbs polka mtmbor and ecplrafte date}
F ailuro to s xure coversee as required under Salina IJA of MGL c. 152 tan led to the imposition of criminal pmdlies of a
Pent up to 11.500.00 and/or ono-year impristortmorK am well as civil penalties in the form of is STOP WORK ORDER and a floe
Of up to S230.00 a Jay against the violator. Ile advieod chats Cully of this statement maybe forwarded to the Offfco of
In.c.ugariuns.d'dre MA far insurance coverage vcridLidiout.
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City or ruwn: Prrmir/Llcenoe e
Lnuing.\urhentylcircteunel:
I. Ituard of Ilralult 2. Ruwhting tleparemunt 1. Ciiy/rows Clerk J. Electrical Lnpeclor S. Plumbing Impactor
L�,olacl Pcnon: - . _ .. Phone a:
CITY )F SALEM
�.
PUBLIC PROPRERTY
a' DEPARTMENT
ttl I: N I 1 ' Mlr I'I I I IC�',1d II\I...1`l 1'NkC T �•111\1, S1.94,01 kit J
Construction Debris Disposal Ariidavit
(required lur all demolition and renovation work)
In accurdwIce with the simit edition of the State Duilding Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40. S 54;,is issued with the condition that the debris resulting b'om
_
Building Permit p is waste disposal facility as dafined by MGL c
i this work shall he disposed of in a properly e wi
111. S 150A.
The debris will be transported by.
C Ie, viol 4J✓v{ ✓� .' I i
p,sme of hauler) _
The debris will be disposed of in
(name ulxl Ity
Ci
(address ul lacililyl nn
/J
a uature of pa in "I t" :am
5
date