47 GALLOWS HILL RD - BUILDING INSPECTION a I'hc Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
OF SALEM
Massachusetts State Building Code, 730 CMR, 7"edition
�,a f Revised A n Wry
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, 200,1
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Nu er: ate Applied: //ll
Signature: 4, /)/-q//,)
Building Commissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
I.1 ProperrlJyy Address: 2 Assessors Map& Parcel Numbers
)llo vS l-hI/ kcl 70
1.
X70
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(sq It) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Require) Provided Required Providcd Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private 13Zone:
if es❑ Municipal❑ Onsite disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 QQwnerl of Reegqo: I
�- ;Da
O�OUCvSL. {� C3aIIC��S �
Name mt AJJ sns forpService:
Signature Telep ne
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ 1 Existing Building Cq Owner-Occupied 121 Repairs(s) 01 Alteration(s) ❑ 1 Addition ❑
Demolition Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': ct owg
S
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
I, Building S 1. Building Permit Fee:S Indicate how fie is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost(Item 6)x multiplier x
3. Plumbing .S 2. Other Fees: S
4. Mechanical (IIVAC) $ List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S aDW—00 ❑ Paid in Full ❑Outstanding Balance Due:
019-70
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of*CSI.- I folder List CSL Type(see below)
TvPC Description
Address U IlorestricteJ(tip to 35,000 Cu. Ft.)
It Restricted 1&2 Famil Dwellin
Signature I M Nlasonry Only
RC Residential Rooting Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
Ii IC Company Name or HIC Registrant Name Registration Number
Address
Bxpimtion 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.......... ❑ 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
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
1, as Owner or Authorized Agent hereby declare
that the statements formation on the foregoing application are true and accurate,to the best of my knowledge and
behalf /
ort 19ov1
Print Name
Signature of Owner ort rized Agent Date
(Signed under the sins enalties of er'u
NOTES:
I. An Owner who obtains a building permit to Jo his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(IIIC)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 I IO.R6 and 110.115, respectively.
). When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) Ilabitable 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 (inclosed Open
3. "Total Project Square Footage"may he substituted ror"Total Project Cost"
CITY OF SUF.Nf
PUBLIC PROPERTY
DEP. M. LENT
o.a.a►av eremu
Vw+v 1311wAx4W@G Wsnsar•11m— wan&Sametlb
ML 1'6-7+5.9s"•F.4x 178.7 &994
HOMEOWNER LICENSE EXE.MPTIOr
Pbs" Prime
Date );Q,- 9 - D
Job Laeaties w I i2cA Sct- I
Home Owner Address Oc4 tem rnWe-icu)�
Home Owner Telephone
Present Mailing Address ao3 use ch e�� 61 n L. !7.. �
1 , rn i4 0 r9��
The current exemption o/"Homeowner"was extended to include owner-occupied
dwellings of two Units or less and to allow such homeowner to eagags an individual for
hire who,does not possess a licens%Provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Person(s) who owns s parcel of land on which he/she resides or iaterds to reside.on
which there is, or is intended to be,a one or two family dwelling, attached or detached
structure 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 SIGNATLRE LLA �\
,APPROVAL Of BUILDING INSPEC'fOR
See other side for state code
CITY OF S'ULE.4NI, %L-kSSACHUSETI'S
• BULDLNG DEPARTMENT
120 W.�.SHLYGTON STREET,Y°FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
)uSjBEyj EY DRISCOIL
MAYOR THo.�IAsST.PtERRe
DIRECTOR OF PUBEX PROPERTY/BtADLNG COXMISSIONER
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 I l 1.5
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:
3:CXAn //aL-�/ .ei s
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
"Sigunaof permit applicant
�a-
tel - ) O
date
IcbrwIr dew