23 WOODSIDE ST - BUILDING INSPECTION (4) The Commonwealth of Massachusetts
"11 Board of Building Regulations and Standards Town
Massachusetts Slate Budding Code, 780 CMR, 7'"edition Building Dept
Q Building Permit Application To Construct, Repair, Renovate Or Demolish a toonowkis
One-or Two-Funtrti Dit elling Anna
This Sectio For Official Use Only
Building Perini N ber: Dale Applied:
X Signamte: _ 3( l/f O
Bull no u 1 ofButldmga Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 5✓ SALG�1. 1.2 A+sesson Map s Percti Numben
X WDDDSrDv i
I.la Is this an acce ied streel7 yes ✓ no Map Number Parcel Numbs
IJ Zoning Information: 1.4 Property Dimensions:
Zo ing District Proposed Use Lot Arcs(sit(1) Frontage(A)
1 3 Banding Setbecks(it)
Front Yard Side Yards Rem Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1.c.40.154) 1.7 Flood Zone Information: I.g Sewege Dbpoul System:
Zorw: _ Outside Flood ZoneT Munieipsl O On site dispossl system ❑
Public O Private O Check if yc913
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: L 3 cN p0M i i7C S SR L O` n
-/'i /uL�'�OBt9�
Na c I Pr nit Address far Service:
q? e t 17YO, 6 96i
onmee - Telephoner
SECTION J: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction Existing Building O Owner•Occupicd O Repairs(s) D Alteration(s) O Addition O
Demolition O Accessory Bldg.O Number of Uniu_ Other O Speciry
Brief Description of Proposed Work
aV,jI
SECTION 4:ESTIMATED CONSTRUCTION COSTS
MS (O
Official Use Only
*Project
g I. Building Permit Fee: S Indicate how rev is determined:
O Standard City/Town Application Fee
Electrical O Total Project Cost'(Item 6)a multiplier a
ng 2. Other Fces: S
nical (HVAC) List:
tcaf (Fire Total All Fees: S
n
Check No. _Check Amount: Cash Amount:_
roject Cost Paid in Full 0 Outstanding Balance Due
F ,
SECTIONS: CONSTRUCTION SERVICES
9.1 Licensed Construction Super%isor(CSL)
� Laenw Nlumtkr Espuunon Dare
Npoe tat L SL Hplder Lets CSL Type(Kv h0uw)
a T Description
Address
U I Unrestricted(up to 33.1700 Cu. Ft.
R Restricted I!2 Family Dwelling
Srynamre
N %fasonry Only
RC Residential Roolmil Covering
Tclephone W S Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 Registered Home hisprove neof Contractor(HIC)
HIC Company Name or HIC Registrant Name Regtsuation Number
Address
Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,e. ISL 12SC(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 Allldavit Attached? Yes..........O No...........O
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.
Si stureo(Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1, ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are we and accurate,to the best of my knowledge and
behalf.
Print N
3 /� / A
Sign of Ow or Authorized Agent Date / /
(Signed under the pains and penalties o(perjury)
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hues an unregistered contractor
(not registered in the Home Improvement Contractor)HIC)Program),will go have access to the arbitration
program or guaranty fund under M.G L. c. 1 a1A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R1,respectively.
2. When substantial work is planned,provide the information below: _
Total floors area ISq. Fr.) (including garage, finished basemenivartics,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 hating system Number of decks/porches
Tspeof cooling system Enclowd Open
1 "Total Project Square Footage"may he,uh,muted for"Tool Project Cost"
Ill
CITY OF S UY.�t
PUBLIC PROPERTY
DEPARTMENT
mina AL"erMvv.
Wraa 13a W NV*GT N STIEW•suiK NAaAoti'scns 019`0
TIL V.&745-959s•f.tX 975.74O9s+6
HOMEOWNER LICENSE EXEIMMON
now Mat
Date 3 / I0
job Location L 3
Horne Owner Address Z 3 to o d i>s i A c= ST-
Home Owner Telephone 9 '70 . 7c/() , h9bb
Presed Mailing Address 7 � a-)z7oDs / /A ST
II The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or less and to allow such homeowner to engage an individual for
hire who does not possess a license,provided that the owner acts as supervisor.
DEFII MON 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 dwelling, attached or detached
structures accessory to such use and/or farm structures. A person who constructs mom
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
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 �Lt�
APPROVAL OF BUILONG INSPECTOR
See other side for state code
s
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.1'.II:: Nlhl ! N Iv i'II
\l U• N - I'0 Vf.\+I11.\L:JN)1'NkLT �SA I-\1,N1.Ni.\l 111 -
1'F1:'178•N?•1iy5 1'.%X:978.740.9846
Construction Debris Disposal Affidavit
(required Iur all demolition mid renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit k is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I 11. S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in :
(name If aci ny)
(address of lacility)
,ign ere of(xnnit applicant
date
Icln i.�ll,nti
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Property ID 1701920
,9a Address 23 WOODSIDE STREET
170193 Land Use 101
Book and Page 13253-228
Lot Sue(Acres)
012
' Assessed Value S>:29&,000.00
ti 21
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