15 INTERVALE RD - BUILDING INSPECTION ��tiJ a The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
t ' OF tiALEM
Massachusetts State Building Code, 780 CMR, 7'h edition
Y•'• Revised Januort-
Building Permit Application To Construct,Repair, Renovate Or Demolish a 1. 008
One-or Tiro-Family Duelling
This Secti or Official Use nl
Building Permit Nu4r:
- Date App 'ed:
Signature: "✓ /a/ rl�ly
Building Commissioner/Inspector of Buil m Date
SECT 1:SITE INFORMATION
1.1 Pro erty Ad rens: 1.2 Assessors Map& Parcel Numbers
I
�M rV� l-e. GSD.
L to Is this an accepted street?yes_ no__ Map Number Parcel Numb,'.r
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.do,§54) 1.7 Flood Zone Information. 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owyer'of Re c rd: .
I V
S ; a Lc—
Nume(Print) Address for Service:
(--)Cbl-7co - ayss
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
BriefDescriptyy'on ofPropos d Work': t Z WI�l ' 3 Om ZX 7 dfC /n tesla r'�y
7Y cM G r«w�
n'TI Ftl ro v>15 . �,.r rr+�r. sa✓� �n'I '� ro4rn5
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building S 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S 11
Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S `
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:$
Check No._Check Amount: Cash Amount:_
Total Project Cost: S 007 ❑Paid in Full ❑Outstanding Balance Due:
t► ,
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Nance of CSI.-I lulder
List CSL (see below)
T e Description
Addresstl I Unrestricted(tip to 35,000 Cu.Ft.
it I Restricted 18:2 Family Dwellin
Signature M Masonry Ord
RC Residential Rooting Covering
I cicphone WS Residential Window and Siding
SFResidential Solid Fuel Burning Appliance Installation
U Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
1RC Company Name or IIIC Registrant Name Registration Number
Address
Expiration 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:OWNE r OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and infonnatio&6n the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
de
Signature of Owner or Author'Ved Agent Uate /N 1.
(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(IIIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the IIIC Program and
Construction Supervisor Licensing(CSL)can be found in 730 CMR Regulations 110.R6 and 110,115,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.) 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 Enclosed Open
3. 'Total Project Square Footage"may he substituted for"Total Project Cost"
CITY OF S.u.E.*vI
PUBLIC PROPERTY
DEPARTMENT
u.u•aur n•=•�s
.wvas i]aw�sww-�.>naaT•�a•lwo�oaarnOt•'e
M 976,76-93"•f.%L 975.74&964
HOMEOWNER LICLNSB EXE.MMON
Pleas Frl�t .
Date a- G�
Job Laeados I S N+ �( V° '� P\ D
Homer Owner Addres f (1 L L S
Home Ownss Telephone - -7&0-
Present N(Aling Address 1414 H ATFL S fiC�✓��il'1�
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or tea and to allow such homeowners to engage an individual for
Mm who.does not possess a license,provided that the owner acts as supervisor,
DEF1N MON OF H0110OWNIM
Peraon(s) who owns a parcel of land on which he/she readda or intetde to reside,on
which there is, or is intended to be,a one or two family dweWn&attached or detached
structum accessory to such use and/or farm structuree. A person who conaucts more-
than one home in a two year period shall not be considered a homeowner. Such -
"fameownee sW 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 undenigned "homeowner'certifies that he/she undentands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requir M
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING CiSPECTOR
See other side for state code
CITY OF S'UYENI, NL-kSSACHUSETTS
BUILDING DEPARTNONT
' 130 WASHLNGTON STREET, Y°FLOOR
TEL (978)715-9595
FAX(978) 740-9846
KIJBERLEY DRWOLL
THo
�lAYOA uns Sr.P>Psas
DIRECTOR OF PUBLIC PROPERTY/11VI DLNG COWMISSIONER
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 l 11.5
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:
r F
(name of hauler)
The debris will be disposed of in :
(name of facility)
(address of facility)
f signature of permit appl at
��/�/��
date
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