19 CLOVERDALE AVENUE - BUILDING PERMIT APP -- - ----- -----
_ --------- I hC t 'nnnlr�n is ralih td \Lissac hux•Ils ------- - ------�
HOA!J III I3tIl Ju!c RCp111:1IIOWN ,wJ .S( n dards I ( IIl
i L y Nla>Nac l l USC 111 Stale 1301 IJ ni l; ( ,tile. %SI)( NIR. 7 iJ I(I,iii
13oilding PCl'IIIII Applic-Ilion To Ctni.uuct. Repair. RCm,t.!Ir Or I)rnh li.h e
i
I to Sr,:l in Ftp OlfiLIaI ('.e l)nly
Date .\ flied
BullJinc Prrrnil Numhrr. ___- _ -- _ _ PI
SI n.!!UI
It... ug i_limnu..nmrl/ In i u ,•!i?u� ..dies D.ut
INFOR.M 1'IUN
I.! i"nptpe:yy adress: /e C/.� 1.1 \uessurs Nlup :k Parcel NumberN
' scN In Map Nunlher P.ucCl NwuhC)
Lr Is lhn.tit .tcs rptoJ sir eci - . _- ._- ___ l '
I.S Zoning Infort:mtion: I 1.4 Property Dimensions:
Znnmg District Prn(n r 1 10 I Loi Area l iy Ill h mitn gr ill i
1.5 Building Setbacks (ft)
7
Front Yard Side Yards Rear N:ud
70%ner'of
Presided Required Pn.v ided Hryun ed PI u'iuca
upply: I%I G L c. 40. §5-lr 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Fh>ad Zone:'Pn rate❑ Stumapul ❑ On>itc Jieltsal a.irmCheck li yes❑SECTION ?: PROPERTY OWNERSHIPt Record:
DZid-41 O,k-/ZA
N.In:r i Print) address for Senirc:
Sign:tirre Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK"(check all ihat apple )
New Construction ❑ Existing Building ❑ Ots mer-Occupied Rtp:urs;s) I� :\Iteranonn) ❑Acton m G
Demolition ❑ Accessoiv BILIS.11 - ""Number oi'Units Othar ❑ Specify _ -____ _' J�
Briei Description tit Pr tFosed W .rot: /� /-t✓Li�o� �f'e.S .�tl^j. /�-d['�i9_c-�..-._
Ld'-;77 ) .T�^o-x- - B vi.Ld_..sZ z_ our e Bed ia� G.eoroT gf _-
r .--------- -- - __.. --- -- ----- --- - -- - -- -
--- - - -- t
SECTION 4: ESTIMATED CONSTRUCTION COSTS I
Ecomated Costs:
Ilan Official Use Only
i ILahor.Ind >iaten:dsl ___ —_--- -_--- . - �
I IiwlJmg - 5- I. Building Permit Fee: 5 .- Indicate hrss Ire !. Jrlei unne-I
❑ Standard City/Town Apphcaortn Fee
]. Flectncal i ❑ -rowi Project Cust' iItem 0) s multiplier
3. Plumbing '� _ _'. Other Fees: S
4 Mechanical iH\':\CI
5 }lei h❑nic.tI II e ---------
1uLNsn nl
.— �.� heck No _ ('heck .\momni� .._ _ _—('.Lh \tit,nim
I, fatal Project Cost S,:52 •�Q 0 Paid in Full -- 0 Oubl_InJin_' 13.J,mce I)ue-- -
1
SECTION 5: CONSTRUCTION SER% ICES
5.1 Licensed Construction Superisor l('SI.)
L�pn.it II,oC
N.raC of ('SI. IIoIJCr---_.-- -- List ( SI- 'I\pc wc hClnw
\JJrrs` l l mcsui.icd ulr la
R RCsuwlcd IAC' F.muh Ilw rlluiu� _
ii idnuo \I \i.hPpr\ 1111E
Rl 2c. flojl H,-,-line(-.Heinle
\11 Hsi J;roost NmJi.v ,inJ i:J:n
iF R:.IJ:nli.il SuLJ I'iil lS:unw�\t�L�an._In_i.,li.n,,.i�
.2 Registered Home Improvement Contractor(IIIc)
lilt("nnp.urn .Name or IIIC`Rcgistunt Name —_ Reguvauan NumhCr
I
\ddrcse
Ualt
. F.yw awm
g;:.....r. Fa•_phone
SECTION 6: WORKERS' CONIPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 25061)
Workers Compensation Insurance affidavit must be completed and submitted with [his ipplic tion. F.ulure ni pnis ide
this affidavit will result In the denial of the Issuance of the building permit
Signed Affidavit Attached? Yes .......... O 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 nutters
I .•c.aIIVC i �k k authorized by this building Permit application.
,
Signature ut Owner Date
SECTION 7b: OWNEW OR AUTHORIZEDAGENT DECLARATION
I. / > C-6 Jti7Z-,t G,--Z , as Owner or Authorized Agent hereby deetoe
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
I behalf.
Print Name z fy O g
.Signature of Owner or Author LCB Agent —_ Date ----�--� ---
(Si red under dte PJLns and penalties ofper tip I
NOTES:
I. An Owner who obtains a building permit to do his/her own work, ur an owner koho Lures an unrCgt,ICICd .,nnr,h 1,11
(not registered In the Home lmpnlsement Contractor MIC) Pnigram), will nor hiNe access to me .uhitration j
program or guaramy fund under NLG.I.. c. 112_A. Other unportant mGirmation on the HIC Program and
Construction Supervisor Licensing WSL) can he found in 780(AIR Regulations I MO R6 and I III R5, iespestitcly
' When suhsiamial work Is planned. pioside the inlirmanon below:
Total floors area (Sy. Ft, tmcluding garage. finished hasenient1autCs, de,ks or porch,
Gross Irving arca I Sy. Ft,) Hahn.lble room Count
Number of hreplaees_ Number of hedro,ans _
Nllltthel or hathnionn - NUInhC1 Or ),.Itib,iths
Is pe ,it he.uine ,vstcm ----.,_.---- _-- Number i-I lc,k,,
1 \lie of oiling s�stern__ 1`nJioCJ _. .._____._. 2)P:n
3 I'mal Project SLIu.tre Footage- in.i1 he 'llhltlltlled It 11 rt.11 Pri ilC,f (•osl'
CITY OF SALEIM
PUBLIC PROPERTY
DEPARTMENT
KI"UX5."erw•n --`
130wAl"WGMM 3rWir•&AU1K X%SL%CW-' M 01970
lb:9'.LNy9S99• Fnlc 978-740.99"
HOMEOWNER LICENSE EXE.MMON
Please Print
Date � ' 0
Job Location % %
Horne Owner Address i 9 o vex dg e s!
Horne Owner Telephone 7 0' -:5'Z5 e
Present Mailing Address
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
hire who.does not possess a license,provided that the ov mer acts as supervisor.
DEFwMON OF HONMWNMt
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 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 SIGNATUW�� �son
APPROVAL OF BUILDING INSPECTOR
See other side for state code