15 WILLSON ST - BUILDING INSPECTION (2) The Commonwealth of MaSSttchtlSettS
I Board of Budding Regulations and Standards ,MI NI( II'-AI.ITI :
1 \,lassaChusettS Slate Building Code, 780 CMR, 7"' edition S1
p I
Building Permit Application To Construct. Repair. Reno%ate Or Demolish a Pc� nd -O(6wu,
Otte- or Tina-Funtih Dire/lint 'utt8 �
— -- --
Secuon For Official Use Only
Building Permit Nu ber: ,/_�. Date Ypplied:
Signature:
— -
Bull dln Cumnu. iunri/Iicdor of Bwldwgs Owe
\� SECTION 1• SITE INFORJiATION
Ll Prnr�erh Address: 1.2 Assessors Map & Parcel Numbers
—1✓-fit-�-�S�_S-�[e2�" -- -
11.i `umber I':urel Nmnher
I.la Is !his :m accepted street? ves nu— P
1.3 Zoning Information: 1.4 Properly Dimensions:
Zomng Uutrict Prop,,>ed Use Lot Area (,q t) Frootauc (11)
1.5 Building Setbacks (ft)
j Front Yard Side Yards Rear Y:ad
Required Provided Required Provided Required Pit &I-1
1.6 Water Supply: IM.QL c. 40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone'.' ,bhmicipal ❑ On Site disposal syntein ❑
Public ❑ Pri%ate El Check il yes❑
SECTION 2: PROPERTY OWNERSHIP!
2.1 wnert of Record:
n C� F ►ome�iU� /S GJi'l/sow 4�
Nam (P Address for Service:
e
i(lam �8) 7v S-72 -
s
Si iuturc Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction ❑ Existing Building ❑ ON epairs(s) e Alteration(,) Fdl :Addihin, ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': t - C31 7h.8e Vt —
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials) -
I. Building $ / 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical S ❑Total Project Costa (Item 6) x multiplier x
i
3. Plumbing S 2. Other Fees:
List:
J. Mechanical IHV;1C) 5
5. Mechanical (Fire 5 Total :All Fees: $
Suppression)
Check No. Check :Amount: (L,h Anioulw ---- i
j b. Total Project Cost: ❑ Paid In Full ❑ OutsCmdinu Balance Due:-- --
I
__J
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number I1,\p1mlion Data .
N:mn• of CSL- Holder
List CSL Pc ucr brlots) _
Wdres• I'v c Dcscri won
1. L;IIreSIiiciedtutta35.000Cu. Flt
R Reslneted 1&2 F:muh DN,clhm_
Sign;utuc Al .ALooms Only
RC Restdenuul Roofing C menne
telephone %1S Re idcmul AA'mdot, .and Sidury _ I
SF Rc>idenu:d Sand Fuel Bwmnc A t tl i,mce In.t.ill.wwm
D Re>tdentitd Denwliuon
5.2 Registered home Improvement Contractor (IIIC)
II IC Company Name or IIIC Registrant Nance Regisnation Number-----
Address
E%poutlon Date
.signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6))
_i
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 .......... O No ....._.... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERNIIT
1. as Owner of the subject property hereby
authorize to act on my behalf, in all maulers
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 711h: OWNEW OR AUTHORIZED AGENT DECLARATION
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.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
NOTES:
I. An Owner who obtains a building permit to do his/her own work, or an owner who hires all unregistered contractor
(not registered in the Home Improvement Contractor (HIC) Program), will not have access to the arbiu-ution
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 7S0 CMR Regulations 110.R6 and I I0.R5, respectively.
_'. When +ubstanual work is planned, provide the information below:
Total floors area (Sq. Ft.) (including garage. finished basement/anics, decks or porchi
Gross living area tSq. Ft.) Habitable room count
Number of firrplaceS Number of bedrooms
Number of bathrooms dumber of h:dt/b:uhs _
Type of heating systent Number of decks/ porches ._-- --.--.
ype of cooling System Enclosed Open
3. "Total Project Square Footage- may he substituted for 'Total Project Cost-
CITY OF SAL EM
e
PUBLIC PROPERTY
DEPARTMENT
iu�w�••�•OII1fCOu.
.MAW* 120 W&%UNGTON SUM•SALM MASSACWS"M 01970
M-978-74S.9S9S• FAX 978-740.9846
HOMEOWNER LICENSE EXEMPTION
Please Print
Date 4./9-DS
Job Location __ 1 S U)Ai s a.. 54reA-
Home Owner Address<\. i11
Home Owner Telephone 99i7 7yS-721V .
Present Mailing Address r. -) ram.
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 them 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
f 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 r it ents.
HOMEOWNERS SIGNATUR$,-
APPROVAL OF BUILDING INSPECTOR
See other side for state code
-� CITY OF SALEM
•` PUBLIC PROPRERTY
'a .�`• ' DEPARTMENT
$acET 0 >.wt.,
45-')i95 7t-74G9446
li
I
Construction Debris Disposal Affidavit
(required for all demolition acid renovation work)
In accordance with the sixth edition of the State Building Code, 'SO Cb1R section 111.3
Dcbris, and the provisions of N1GL c 40, S 54;
Building Permit p _ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly Licensed waste disposal facility as defined by MGL c
S 150A.
The debris will be transported by:
4zx
(name of hauler)
I1`.a debris will be disposed of in
htyr.:e.,t Ixlrty) .
I
ill`