58 WILLSON ST - BUILDING INSPECTION (2) CK �gLI5
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
1 Revised Altar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This'S-eblion For Official my
Building Pern ' Number: A D a!9.4ppIied:
7Q AM ors J" 5W,
Building Official(Print Name Signature Date
SEC ON 1:SITE INFORMATION
1.1 Zgerty Address: S T 1.2 Assessors Map& Parcel Numbers
. Cl �..� S Ola�
I.I a 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(sq&) Frontage(It)
1.5 Building Setbacks(ft) -
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner ofG ��
Record:
��t-f L
- . U C=-L./ r—i G-_ S!*-L-- E/VL /)I -'q 0 l [
Name(Print) City,State,ZIP
!;;8 Lk_i' L-L Sd.J ST
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied R I Repairs(s) ❑ 1 Alteration(s) &t Addition ❑
Demolition ,I� Accessory Bldg. ❑ Number of Units >Z Other ❑ Specify:
Brief Description of Proposed Work'-:
/?E�rd %f� '� i7 lZE.3 crLD fKv4/� ST9 / /2S CirP
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ - 1. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical $
❑ Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
6 $ •7�(� �(� Check No. Check Amount: Cash Amount:
. Total Project Cos[:
/ 0 Paid in Full 0 Outstanding Balance Due:
i
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu. R)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
,
No.mid Street
Email address
City/Town,State,ZIP 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 .......... ❑ 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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,1 hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 can be found at
www.mass.eov'oea Information on the Construction Supervisor License can be found at www.mass.sovidps
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.) (including garage,finished basement/attics,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"
J'
CITY OF S.U.&M, A--1SSACHCSE-rrs
BLaDLNG DEPART%MNT
130 W.1SHLNGTON STREET. 3 °FLOOR
TEL (978)745-9595
FAX(978) 740-9846
KI\IBERLHY DRISCOLL
I
MAYOR �IoatAs ST.PtERAB
DIRECTOR OF PUBLIC PROPERTY/lI iMMr.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# 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
111, S 150A.
The debris will be transported by::
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
C:
signature of permit applicant
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CITY OF S.0 EM
PUBLIC PROPERTY
DEPARnmENT
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HOMEOWNER LICLNSE EXEMMON
Pile" hint
Date ✓t= �/- i
Job Lacado. s-e
Home Owner Address S f3 ui.IIS o, 57—
Home Ownet Telephone 37-`,-70 mays s� i 7
Present Mailing Addsaes s 0 tt 7 , i/s a u 1;
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or leas and to allow such homeowners to eopp an individual for
hire who.does not poetess a licrossq provided that the owner acts as suparvism
DEF1NM0N OF HOMEOWNER
Parson(s)who owns a parcel offend on wbkh bds be resides or intends to resdder an
which then is, or is intended to her a one or two firmly dweWag, apached or detached
structures accessory to such use and/or firm squcturea A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeownd'shelf submit to the Building Official,on a fore acceptable to the Building
Offlcial, that he/she be responsible for all such wort performed under the Building
Permit
The undersigned"homeowner'asnm e@ responsibility for compliance with the State
Building Code and other applicable by-laws and reyuladons.
The undersigned "homeowner"certifies that he/she undentands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
.viIf comply with said procedur an equirements.
HOMEOWNERS SiGNATL
APPROVAL OF BUILDING NSPECTOR
Sea other side for state code