4 HILLSIDE AVE - BUILDING INSPECTION s�J
The Commonwealth of Massachusetts Town of
e Board of Building Regulations and Standards
t Massachusetts State Building Code, 780 CMR, T"edition Building Dept
� Building Permit Application To Construct, Repair, Renovate Or Demolish a `
One- or Two-Family Dwelling
This Section For Official Use Only
Building Permit Nu her: Date Applied:
Signature: y/d2/0
Building Commissioner nspector of Buildings Date
SECTION 1:SITE INFORMATION
LI Property Address: 1.2 Assessors Map& Parcel Numbers
LI 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 It) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M,O.L c.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑
Public❑ Private❑ Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
1 Owner'ofRecord: '� J/� de I aLem
�k1 f PS I� id�2✓L_1�Y1 n , 2�
Name(Print) Address for ervice:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupie11:0: Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units—� Other 13 Specify:
,Brief Description of Proposed Work 2: A n 'r � L4 :F40,,-F' bn rr It tat��la—t inrsol
i risTP,a� �.� hr cue
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Ofilclal Use Only
Item Labor and Materials
I. Building E I. Building Permit Fee: 5 Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing 5 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S Total All Fees: S
Suppression)
Check No. _Check Amount: Cash Amount:_
/./ 6. Total Project Cost: S IL/0C), 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) t
a
License Number Expiration Dale
N�iimc of CSL- Hpldcr List CSL Type(sec below)
Address TDescription
U Unrestricted up to 15,01)0 Cu. Ft.)
Signature R Restricted I&2 Family Dwelling
M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel BurningAppliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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.
St iriffire of Owner Dates
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 true and accurate, to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury)
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 1 IO.RS, respectively.
2. 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.) 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 Syuare Footage" may be substituted for"Total Project Cost"
CITY OF S.UX.M
PUBLIC PROPERTY
DEPARTMENT
MAVM 130WASUNGUN STMW•Sub{MASS CMMEM 01970
TTM.97{•715959!• FAX 97L74&964
HOMEOWNER LICENSE EXEMP'T'ION
Please Print
Date`�JV anq
Job Location Vyey Sal��i Alhn
Home Owner Address L
Home Owner Telephone c?7F-
Present Mailing Address '�/ Moe d
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or less and to allow such homeowners to engage an individual for
hire who,does not possess a license,provided that the owner acts as supervisor.
DEFINITION 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 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 "homeownet"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
,APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
'
12" gA,Ilh,..,lN iI \I, \L\,i ! I . _II _
'I 11: 7'N '4;.•);;Jn ♦ I-\c 'i'N V}.'194,,
Construction Debris Disposal Affidavit
(rr(Iuired lar all demolition and renovation work)
In accordance \ ith the sixth edition of the State Building Code, 7S0 CNIR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit N 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 ut'hauler)
I he debris will be disposed of in
(uamr ul lacility)
SQL rn y1nA
taddres ur racililvl /J
.1�uaturc of penurt applicant
G/
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