23 WILLOW AVE - BUILDING INSPECTION "e
The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, T"edition loomww
Budding Dept
Building Permit Application To Construct Repair, Renovate Or Demolish a 1ddO8w�IlOM
One- or Tvo-Furnils Omrlling
is Sectto For Official Use Only
Building Permit Number: Date Applied: s s v
Signature:
Building Commtss ner/ Ins t of ridings Date
CTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map dt Parcel Number
x 23 lnJi II � �
1.Is Is this an accepted street'!yes ✓no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning Distnci Proposed Use Lot Area(sq R) Frontage(R)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Public!7 Private O Check it esO p pO y
SECTION 2: PROPERTY OWNERSHIP'
2._1O_)Vner'of Reeord•`
o ✓sLQ� L/
Name Print) Address for Service:
X � •��. �i�� 978- ��y-� yo2
Signat a Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building❑ Owner-Occupied I Repairs(s) ❑ 1 Alteration(s),V I Addition O
Demolition O Accessory Bldg. O Number of Units__L I Other ❑ Specify:
Brief Description of Proposed Work': Zvi S O ct
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OlOelal Use Only
Labor and Materiab
I. Building S 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical f
❑Total Project Cost (Item 6 x multiplier x
3. Plumbing T 2. Other Fees: f�
4. Mechanical (HVAQ S List:
5 Mechanical (Fire T Total All Fees: f
Su ression -
Check No. _Check Amount: Cash Amount:
X A. Total Project Cost: f 2„ Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
7Ltceme Number Expiration Date
Nyoe of CSL Hylder List CSL Type(see below)
T Description
Address
U Unrestricted u to 35,000 Cu. Ft.)
R Restricted 1&1 FamilyDwellin
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.f 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........... O
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 authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
G as Owner or Authorized Agent hereby declare
that the sta emen and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf. a.rvard Al. / nL—
( � Print N �` 01- �` O
Signature of Own or A orized Agent" Date
St tied under the ams d penalties ofperjury)
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 jI 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 110.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
Ts pe of cooling system Enclosed Open
3. "Total Project Square Footage" may he substituted for 'Total Project Cost"
CITY OF SALEM
r`—y PUBLIC PROPRERTY
DEPAWINIENT
Construction Debris Disposal Affidavit
(lk:quircd l6r all demolition :old renovation \vurk)
fit accordance %%ith the sixth edition of the State Building Code, 7SO CAIR section 1 1 1.5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit K is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal I'licility as defined by MGL c
I1I. S 150A.
The dchris will be Iransported by:
-re �>
I name tit hauter)
I Ile debris will be disposed of in
Iodine tit I'acJlrty)
l.o1Jre.. ..I'I].Jilyl
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CITY OF siuyEm
PUBLIC PROPERTY
DEPARTMENT
WY06 130 wA9amcraw SnFtT 9 94a4 AAsL omsans 01970
TEL 97a-745.45"9 F.AX 978.74&904
HOMEOWNER LICENSE EXLMPTION
Plow "
Date
Job Location 23 tv //o W µe
Home Owner Address 23 o w v ve - (
Home Owner Telephone 97 - 7�! — c L 9.7d'- 57B 5i J?
Present Mailing Address s a CLS 110
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or lea 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 lard on which he/she resides or interds 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 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