11 WILLSON STREET - BUILDING INSPECTION ® = z
No. 53UPC 103
E 3
HASTINGS, MN
C-9LL-S—:5-b i C -40N3-FMM P_
Fhe Commonwealth of Massachusetts �t /7� )�
a Board of Building Regulations and Standards RECEIV 0p �l l'
Massachusetts State Building Code, 780 CMRINSPECTIONAL X24(vHf x4201/
:;.
Building Permit Application'o Construct, Repair, Renovate Or Demolish a �S
One-or Two-Family Dwelling JUN —2 3: 39
This Section For Official Use Only
Building Permit Number: Date Append:
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
1.1 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 Arca(sq Il) Frontage(Il)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
Lfi Water Supply:(M.G.L.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: __ Outside Flaod 7 ne?
Public Private❑ Clreck if y� MunicipalOn site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 nert of Re•ord: L p
Na e(Print L C'ity,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ 1 Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ' •city: Wol
BriefescriptionofPropoedWork1'':_
(.It1
IA lA4 LV i) 0.� ( + K�v✓ t vnC ,
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building $ S' OPP� 1. Building Permit Fee: $ Indicate how fee is determined:
°. Electrical $ ❑Standard City/I'own Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. I'vfechanical (MVAC) $ List:
5. Mechanical (Fire $
Suppression) Total x111 Fees: $
li. 'fotal Prom
Check No. Check Amount: Cash Aount__
,jec[ Cost: $ SQVU� ❑ paid in Full ❑Outstanding Balance Due:
fUlatt.- -rp x _ b .
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
3
ri i,;t. License Number Expiration Date
Name of CSL Holder
List CSL'fylw(sec below)
,R r' t,rJt ',ins
No.and Street � TYPe Description
U Unrestricted Buildin s up to 35,000 cu. ft.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Reading Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Tele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(1-11C)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Finail address
Cit /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, I hereby attest under the pains and penalties of perjury that all of the information
contained i v is a lication is[rue and accurate to the best of my knowledge and understanding.
Print Own&'s or Authorized Agent's Name(Ilcctmnic 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(FITC) 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.ntass.¢uv/oca Information on the Construction Supervisor License can be found at www.mass.gov/dips
27 When substantial work is planned,provide the information below:
"Total floor area(sq. ft.) (including garage, finished baseniendattics,decks or porch)
Gross living area(sq. ft.) I labitable 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. "notal Project Square Footage" may be substituted for"Dotal ]'reject Cost"
Cite of *alem, AIaggarbugettg
3publi[ Propertp Mepartment
3guilbing Mepartment
Otte batem green
(978) 745-9595 ext. 380
Peter Strout
Director of Public Property
Inspector of Buildings
Zoning Enforcement Officer
July 10, 2001
Stavos Moutsoulas
11 Willson Street
Salem, Ma. 01970
Dear Mr. Moutsoulas:
This department received a complaint about building materials and debris up against their
house.
I took a look at the situation and found building materials, ladders and construction debris
on a rack, which then rested on your neighbor's fence.
Also, a shed was built without any permits.
Please contract this office within ten (10) days upon receipt of this letter to discuss this
matter.
Sincerely,
V / L�p�voJr�,v � �—ce�•,1,
Thomas St. Pierre
Local Building Inspector
cc: Mayors Office
Councillor Lovely