35 WILLSON ST - BUILDING INSPECTION a The Commonwealth ol'Massachusetts
Board of Building Regulations and Standards CITY
t�' ,n OF SALEM! Massachusetts State Building Code, 780 CMR, 7 edition I� Revised huurun•
Building Permit Application To Construct, Repair, Renovate Or Demolish a /• -'///!x
n�V One-or Tn' -Family Dwelling
II U h' Se ion For Official Use Only
Building Permit Number: Date Appr
Signature:
Building Commissi er/Inspec o I uil mgs Dale
TION I:SITE INFORMATION
I.I Property Addre;s: 1.2 Assessors Map& Parcel Numbers
/ =771-50� ST
I.la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sy 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Provided Required Provided
Required Provided Rcyuired
t 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone'? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑ P P y
SECTION 2: PROPERTY OWNERSHIP'
Owner'of Record:
L at3ErT Pfyss.yi?�
Name(Pri t) Address for Service:
. ibnature 'relephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Esisting Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory BI .❑ _NAtmber of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
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:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)a multiplier x
3. Plumbing S ? Other Fees: S
4. Mechanical (IiVAC) $ List: �A✓/�
5. Mechanical (Fire S
Su ression Total All Fees:S
�� Check No._Check Amount: Cash Amount:_
6. Total Project Cost: S '� J S,) `!S 13 paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Dale
Name W CSI.- I loldef
I.ISI CSL IypC(see below)
I'Voe I Description
Address U I!nrestricled(UP to 35,000 Cu. Ft.)
R Restricted 1&2 Family Dwellin
Signature M %Aasonry Only
RC I Residential Routing Covering
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 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 .......... 13 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
authorize to act on my behalf, in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
� /l �-r-SECTION 7b: OWNERI OR AUTHORIZED AGENT DECLARATION
1, 1/o iJ r C / 9b , 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
beh I .
PrOnf am
tiignature 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 an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program), will not 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 110.116 and 110.R5, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Grass living area(Sq. Ft.) Ilabitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of hal0baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage" may he substituted for"Total Project Cost"
CITY OF S.UEN1, .L-kSSACHUSETTS
Bt.IIDLNG DEPARTNtENT
' 120 WA.SHLNGTON STREET,3i0 FLOOR
TEL (978)745-9595
FAX(978) 740-9846
KISBERLSY DRLSCOLL
MAYORTHows Sr.Plvvrn
DIRECTOR OF PUBLIC PROPERTY/BUILDNG COMMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit Al 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
I It, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit applicant
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CITY OF S.ULY-M
PUBLIC PROPERTY
DEPART-MENT
iu.a AL"04WUXL
W Wes I-30 wA"PAG"STUNT•SA"— %"MA0%ram 019 e
raL 9'8-74S.93"•F.%L 971.74&904
H0ME0WNER LICENSE EXEMPTION
Pfesse"t
Date 6)q-
Job Locadas
Home Owner Address 3 5- U/i L-t-5yn- S 7 ,
Home Owner Telephone 97 1?- 7 q i— 7 3 4,
Present Mailing Address
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.dam not possess a lieenss4 provided that the owner acts,as supervisor.
DEFINMON OF HOMMOWNER
Persons)who owns a parcel of land on which he✓she redden 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 O®ciak 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 reguladoaL
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 andrequirements. ,/ /
HOMEOWNER$ S(GNATL7i:: t�-^�/ (� --"'"-`�' t
APPROVAL OF BUILDING INSPECTOR !/
See other side far state code