18 WILLSON ST - BUILDING INSPECTION (2) I'he Commonwealth of b9ussachusells Board of Building Regulations and Standards CI'I'1' OF
Massachuselts State Building Cude, 7SU C'NiR ti,\Lli.\I
Building Permit Application To Construct. Repair, Renovate Or Demolish a
One-or rn u-f'untdY Dm ellin•Y
This Section Fur ORicial Use Only
Building Permit Number: Date. lied:
fr t\ 2
IluilJing Otlieial(Prin Signatum ale
SECTION 1: SITE INFORMATION
L I Property AJJrer. 1.2 Assessors Ma S Parcel Number
1 �LC71I�cn.n S + SGIPrn P _
I.la Is this an accepted street?yes no Map Number Parcul Number
1.3 Zoning Informationt Li Property Dimensions:
Zoning District Proposed tlsc Lai Arun Isq III Fronlugu(11)
1.3 Building Sttbacks(Q)
Front Yard Side Yank Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.4U.§54) 1.7 Flood Zone Informations I.g Sewage Disposal System:
Ihrblle O Prh asu O Zone: _ Outside Flood Zone? municipal ls7�Dn site disposal s)slum O
Check if yes0
SECTION2. PROPERTY OWNERSHIP'
2.1 gwnerrofRecordt
L U(' tJ t�rnYC ! SQ /Plr AIX D157
\/ N;unu(Prnl) ('ity.Slate.ZIP
c -- 5'7f-82fr-gzr63 Shyr�yr r/i�.�3�,)✓vr,' ,, ,re f
Na.:utJ Stout Telephone I11tlY11 Address
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction E.risting Building O Owner-Occupied ® 1 Repairsls) O Alteration(s) C) I Addition t]
Demolition CI I Accessory Bldg.0 Number of Units_ Other C Speedy:
Brief Description of Proposed Wark^
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OMCIuI Use Only
I Luhur and .\I:uerialsl y
I. Building S 1. Building Permit Fee: S.Indicate how f'ee is determined:
'. l:'leelrieal S O Standard CityrTuwn Applieation Fee
17 Total Project Cost'(Item 6)x multiplier _.—_x
1 I'lunihiitg S +, Other fees: S.
4. \Ireh.utieal III\ \('I S List:._
\Icch.utie,d IFire
`u„resionl S rotai .\Il Fees:
D ('heck No. ( reek Amount: C.uh \motmi:
./ 0 1'ulal Project Coo: S ❑ Piid in Full O Uulslanding 11,d,meu Duo:
n
St.*(`PION S: ('ONSI'Mici-ION SFRVICFS
i.l C'unstructimt Supen'isur License(C'SL1
I ieen,c Nuulher ._... .... I ylirnion(late
N,uoe of(St. Holder
IutCSl. l)pe(Sec
l,clutU._—.- _
__ . _.--- '-`--'--- '1'�pe. Ucx'ripliun
No. and 5ea1r
-_---_— -- � (I IhlreilrieleJ Ilhlildin Is up m 1111112 cu. It1
_ R Rc,nictcd Ilt! f.unil Decllin
C'tls "mo,State.LII' _—.----_—. . . ..%I Mason
RC Rmlin Cowrin
µ'S h'indow.md Sidin
.— SF Solid Fuel Iluming Applies ct:5
I Insulation
1'cly hone hinuil aJJrVvm D Demolition
4.2 Registered Ilume Improvement Contractor(HIC)
IIIC Ragisinubn Number licpiraliun Date
I IIC Compin) Name or IIIC Registrant Name
No.Aid Strcct E'mail address
City/Town.State ZIP rele hone
SECTION Ill WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c. 132.1 25C(Q)
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...........O
SECTION 7s: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.
Print Owner's Name(Electronic Signature) Data
SECTION 7b:OWNEW 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 thicalio J me and accurate to the best of my knowledge and understanding.
116 caner Or.\uthohivil �cnt's aloe I llecronic Signaluml ate
NO'rESt
L .\n Owner who obtains a building permit to do his.her own murk,or an owner who hires an unregistered cuntracsur
(not registered in the Hume Improvement Conractur l H10 Program).will Wu have access to the arbitration
program or guaranty found under M G,L.c. 142A.Usher important information on the HIC Program can be found at
I Information on the Construction Supervisor License can be found at,tt,t, 111.1,;V\ '111`
—la
hen substantial twrk is planned,pro\ide the inibrinatiun below!
rota) flour area t sy. 11.1 _ __._t including garage, finished basanlent attics.decks or porch)
Gross his ing area I sq. t1.1 Habitable roam count _ .. ... .
\unlberotlircplaces .. .. --- \umher tit*bedrooms _ . . . .
\umhcr of bathrooms Number of half haths
rtpeot'he.uingi)dcnt . . . . . \'unlhcrordecks. pordws
,11
(\pe I�Oohng i),lem I�I1CI1heJ I CII
1. "I olA Proly" Stitllre lnot.lec 111m J,e,uh,ww,;d lbr'•I1nal Project Co,t"
CITY OF SALE.M
PUBLIC PROPERTY
DEPARTIMENT
KP��La7.urvY• -
VAYO 13S WU O1MMM near•SAL^XmL#,a t Srm of 1'e
M V&745•9s"•FAA 978710.9646
HOMEOWNER LICENSR EXE.IWT ON
Plsw rube
Date / / LIZ,
lob Location w ; l l s o -I
Home Ownar Addreaa W
Home Owner'Telephow — 3
Prend Molding Address
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings*(two Units of leas and to allow such homeowner to engage an individual for
hire who.dam not possess a liomser provided that the owner sets as supervisor.
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of htsd on which bWsM resides or intanife to redder an
which there is, or is intended to ber a one or two family dweWmg, attached or daubed
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 forts 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 bylaws and regulations.
The undersigned "homeowner"certifies that he/she undentands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
wi It comply with said procedures and requiran is
HOMEOWNERS SIGNATURE
CTO
APPROVAL OF BUILDING O
See other side for state code