23 WILLSON ST - BUILDING INSPECTION a The Commonwealth of Massachusetts
ITY
Board of Building Regulations and Standards OFSc AL
EM
t/ Massachusetts State Building Code, 780 CMR, 71"edition Revised Jun uary
'w Building Permit Application To Construct,Repair, Renovate Or Demolish a i. 1008
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit No Dale Applied:
Signature: (�
Building Commissi /Ins for of Buildings Date
SECTION 1:SITE INFORMATION
x 1.1 ProperAddress:ty 1.2 Assessors Map& Parcel Numbers
�3 o%l.�s�x! a7;
L l a Is this an accepted street yes_ no Map Number Parcel Number
1 3 Zgning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(It)
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,§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 ❑
rat SECTION 2: PROPERTY OWNERSHIP'
No a(Print) Address for Service:
X
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': n
k !�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard CitytTown Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Su ression Total All Fees:S
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration(late
Name of CSL-I lolder
List CSL Type(see below)
.Address rvoc Description
U unrestricted u to 35.000 Cu.Ft.
R Restricted I&2 FamilyDwvllin
Signature M MasonryOnly
RC Residential Roofing Covering,
fcicphone WS Residential Window and Sidin
SF Residential Solid Fuel Bumin A liance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
Registration Number
I IIC Company Name or HIC Registrant Name Re B
Address
Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.11 c. 152.1 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..........O No...........13
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, , as Owner of the subjecaproperty 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
I, 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
Xbehalf.
tm421rr=-DP, C-, EEVC►2
Pr��n�Name �l U D o ^
rsl -. �.�—
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of 'u
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 U(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 I O.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/anics,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"
I
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CITY OF S.U.E.Nf
PUB11C PROPERTY
DEPARTMENT
.NAvo0 t as m.�ou snFsr•su.oa Vwa�oasarn Otfro
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HOMEOWNER LICENSE EXLMFTION
Flew Purist
Date
Job Location
Home Owner Address
Home Owner Telephone
Preset Mailing Address . 47771E_
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or leas and to&pow such homeowners to engage an individual for
hire who,does not possess a license,provided that the owner acts as supervisor.
DEFINMON 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 dwellin&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 wort 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 NSPECTOR
See other side for state code