7 WILLSON ST - BUILDING INSPECTION r I he l'tanmonl%calth ill \lul+.K1111S t(, J - --- --`-- -
It
.r \ lio.!rd :H 13ulldinC KCgulauun+ .ulJ St.u!darJ+ Nil �I( IP \1 i I 1
'" t Massachusetts SIAC Iiiti ld inc ('odd. till l \IR. 7 ail n!
1uilding I'ennil :\ppliCalirm Ft 'unsllm:f. Repair. KCnola0. ( h Dellioli+h a
(\
I r u [oo /iunl/1 On,/hrle
�_-- I a Sr' n in For Official t\e Only
B,11dinu I et'nul 'wnhheerr. — _ ! Date .-ApphrJ'. •. __ __ —__ -.__ -
I t wg Canuni.,n Cv npe+I , I ISudJ mg+ U.ne
__-_ ----
I [ON I: .SI IT INFORM \ I'11)N— -- --
1.1 Property Cddress: --------- � 1.2 \sseswrs Nlap & Parcel Numbers
this
Lla Ithisall .hiepleJ +n'eel:' - no_ — I \lap N.....
\e+ —oo _—
i.-) I 1.= U'rl�r•�.rV Lli f']L.^,••!U t!5:
I Li
Zoning Du;ncl Fnrntage iltl
).5 Building Selbeas lfn
T -- --
i Fran! YarJ i Side Yards Krar Y:uJ --�
R eyun CJ Pro%iJ•d Required _RoriJed Keyuu eJ —_ _ Pn„Id,d i
�1.6 \1'ater Supply: LM G L c. 40. §541 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Floot Zone" Muniel al On +ne Juh 71+a1 +s+Ieu! ❑
Puhhc-✓. Pr!cale❑ Check it yes(
P
SECTION 2: i'ROPERTY OWNERSFIIPr
2.1 Owner!of Record: --- l
i �rberi Mall0.�d SK '7 Wlllso✓I 5r
\.ur.• Vnnl i Addre+s lox Ser+tee:
47g- 93o -666Y i
Sure -- — Telephone _.-
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Cl:nstruCt nI ,0 Existing Building Cl Ouner-Occupied ❑ Rep:unl+) ❑ :\heratu,m,1 O�\JJlu��n ❑
Drm.tlilion '❑ Accessory Bldg. ❑ Number of Units__- Other ❑ Spent)
line!D:a'_r!p(um of Proposed Work
-.-
`�O CO--_-frf G+ VID/c\('CD!l bun
-
SECTION is ESTIMATED CONSTRUCTION COSTS {
Item Estimated Costs. Official Use Only
i LaNq and Malenulsl
-_-_.-_ OO j I. Building Penns 1 ee: $ Indicate huu lee i, Jetot owned:
i Budding � DOD - --
!-- ❑ S(andard City/Town :\pplicaunn Fee
'. F.lertncal 5
❑ Total Project Cost (Item GI \ multiplier _ \
Plunihine ) �. Other fires: 'S
1 1 Slechamcal tIl\':\C) S L.uc_
Slechanrc.il !Fire � L�n
\ al All Fees:
----
e� ( hcck No _ l hec mu k \I - nl C.I,h \nt"wn!
(I' b FUIaProject Cost I ) �/, Odd 0 Paid in Fall ___ 0 OuRLInJing B_ILIn.c 1)!:�_
SECTION 5: CONSTRIIC ION SER%IP.- ----- — — �
�.I Licensed Construction Supervisor (CSI.)
Li.cn,c NunJ,cr If,lni.0 n:n U.uc � , �• '
1 \atne n CSI. IIoIJer
— -- Lnl lSl. 1's pc :,rr hctuwi .____.__-_-_
-- — --- 1% x• Uc,a .ion
\ddrr,.
' l l nrc,u i.teJ pup to ��.1M111( u I�t
R Rc,1141eJ I.V_' F.unih Dw.•I ltug�______ __—_
fcicphone �I—\\S—�Ri,tdr n(i.,l \kwd.... ..Id i,Jui-' ..._ ._ _._
5.2 Registered Home Improvement Contractor MHA —
I
H Il' Cuny,.u,v Name or IIIC RegisIrJllt NJlne Regl?II'JIIUIt Numhrr
\ddws, —
F4p11Jtlun Dale
Signature relephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (11,1.G.L. c. 152. 9 2506))
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
iauthorize to act on my hehalt. to all mattcn
relative to w:.0 authorized g p
k hd by this building application.
i I
Stgnature of Owner Date
SECTION 7h: OWNERI OR AUTHORIZED AGENT DECLARATION
1 , as Owner or Authorized Agent herehy decime
t that the statements and information on the foregoing application arc true and accurate. to the best (it my knowledge and
behalf. -
k
ame
ureof OwnerorAuthor zed Agent Date
dunder the urns and nalties of (u )
NOTES:n Owner who obtams a budding permit to du his/her own work,or :mowner who hiresan unreLi,tcted c��ntra.1� 1
ot registered in the Home Improvement Contractor I H1C1 Programs, will rent have access it, me athitrauun j
program or guaranty fund under M.G.J.. c. 142A. Other important information on the I IIC Progr:un .ind
Construction Supervisor Licensing WSLI can he found to 780 CNIR Regulations I I0.R6 ,mJ 1 IU R5. re,pcvtivcle
When ,uhstamial work is planned, provide the information below:
Total floors area tSy. Ft.t t mcludtng garage. finished hasemen Uattics. Jerks .a por,h:
(ir),s living area tSy. Ft.l Hahuahle rnnm rnunt _
Nuwnbernl fireplaces_ Number td hCJF01 an,
Numhet of h:uhtoom, _ Nwnher or h.dlih.tth, .-
I\l,e �11 hearing ,v,trm Nwnher „t Jevk„ ptashc,
3. "ror.tl Project Square Fnulage" rn.t\ he ,nh,tituied rttr ..rot,J Pryect
CITY OF S.UXEM
PUBLIC PROPERTY
DEPARTMENT
NAroa 130 WASWAGTM 51"M 9 SAiJMk yAaAaR::rn 01970
TVL 9"8.74S-9S9S o FAx 975-746964
HOMEOWNER LICENSE EXEMFn0N
Plow Print
Date 2� Zoos
Job Loeatim 7 GU i 1 I Son
Home Owner Address -7 w ttl Son sT
Home Owner Telephone q 7g-9 30 (.( 61
Present Mailing Address 7w ;u so n 56"
The current exemption of"Homeowner"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 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
CITY OF SALEM
P PUBLIC PROPRERTY
DEPAR`I'MENT
I II 7'8--4;-');v ♦ P\\: 'i78-V:_ 671
Construction Debris Disposal Affidavit
(re(luired lirr all demolition and renovation work)
In accordance ith the sixth edition of the State Building Code, 780 CNIR section 1 1 L5
Debris, and the provisions of'\viGL c 40, S 54;
Building Permit it is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal lacility as defined by MGL c
111, S 150A.
The debris will be transported by:
(�v`l✓� 1�J2L.2cICa
(name of hauler) -
I he debris will be disposed of in
Noy iii fc(( Ca- 11.4 j
(name of lacility)
IadJren.o(1'anlity)
,iguaturc of permit .applicant
date