53 INTERVALE RD - BUILDING INSPECTION I
6Signature: The Commonwealth of Massachusettswn of
Board of Building Regulations and Standards Tnssachusetts State Building Code, 780 CMR, T°edition Buildi-now I
ng Dept
mit Application To COnstmct, Repair.Renovate Or Demolish aOne- or Two-Fmnih'Duelling tt�Section For Official Use Onl Date Applied: ' j dioner! uddings Date
SECTION 1:SITE INFORMATION
1.1 Pro erty Addresr. 1.2 Assessors Map& Parcel Numbers
S� l�r✓ya.Le �o�. �X l�3l0 /�L/7 ,;2/-CJyGP/
L la Is this an accepted street'?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
,�L9 nrrQ /�_,O /V a?r� z3s / ZZ,
Zoning District Proposed Use Lot Ares(sq R} Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard I
! Required Provided Required Provided Required Provided
�Q
1.6 Water Supply:(M. L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewag�e/1�isposal System:
Public 11Privmc C� Zone: _ Outside Flood one? Municipal H On site disposal system ❑
Check if es
(
SECTION 2: PROPERTY
�OWNERSHIP' f
2.1 Of Rgcord: . /G iLO(f ix t:Yl° 7G
Alla
'0::A/
a ✓ 1711 o/y7o
Name(Print) Addr s for Service:
;Iel 711) 33 S-� so
Signature Telephone
SE TION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction Existing Building❑ 1 Owner-Occupied Ed I Rcpairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition O Accessory Bldg. ❑ Number of Units1 I Other O Specify:
BriefYDt��escription of Proposed Work': ' a
,1Us3�ccav� n VIA__] CaCa^, \
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ 1. Building Permit Fee: S ndicate how fee is determined:
2. Electrical S C3Standard City/Town Applicaliolli Fee
❑Total Project Costs(Item 6)x multiplier x
3. Plumbing 5 2. Other Fees: S
4. Mechanical (HVAC) S List:
s. Mechanical (Fire S
Su ression Total All Fees: S
Check No./AA?F Check Amount: Cash Amount:
6. Total Project-Cost: S Paid in Full ❑Outstanding Balance Due:
�raL1 444/4- dj?o'- 22 S - 5223
W KFS✓ llf>�!�'2a�,
SECTIONS: CONSTRUCTION SERVICES
I
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL-Helder List CSL Type(see below)
s
Address FDRcsi"�dentjal
Destro lion
tncled u to)5,000 Ca. Ft.)
Signature cted 1&2 r.Dwellin
Telephone mial Solid Fuel Burnin A liance Installation
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. 152.1 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 .......... 0 No...........❑
SECTION 72.0
a: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:OWNEW OR AUTHORIZED AGENT DECLARATION
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 ofperjury)
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 I IO.R6 and I 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.syslem Number of decks/porches
Type of cooling system Enclosed Open -
1 "Total Project Square Footage"may be substituted for"Total Project Cost"
•t
CITY OF SALEM
ROUTING SLIP
New Construction_
Certificate of Occupancy c���
LOCATION ,g3\_ e-4 vdA� , ATE 1(�(
ASSESSORS DATE
93 Washington St.
CITYCL K DATE
93 Wa mgton St.
PyjQ(ti� OV�'♦'4C�VV.IOQ�ai�k �(u�rF
PUBLIC SERVICE ATE
120 Washington St. 3We�-
WATERTE 7 cZ �7 j1tZ Q lGt�✓G� �
120 Washington 9t.
CROSS 1 f VECTION DATE
5 Jeff on Ave t
VPLANNING . Lin �& ?t-_�� tDATE �al6l
120 Washington St.
\,/CONSERVATION DATE y 1 0
120 Washington St. 1w,4w, w,, a," f,'1- rn f 6 xo�c
ELECTRICAL DATE
48 Lafayette St.
FIRE PREVENTION DATE
29 Fort e
HEALT C �� DATE d
120 Washi gt St.
BUILDING INSPECTOR DATE
120,Washington St.
CITY OF SALE�Nf
a - PUBLIC PROPERTY
DEPARTMENT
K11WF11�y' 'w-n
NwYM I30wAgWAGWM SMEST•S4r_rx VASWNLSUM01970
TEL 9'6.745-9S"• F.kjL 978-740.9646
HOMEOWNER LICENSE EXEMPTION
Please Print II
Date 15 .
Job Location S 3 I w%s rLVla-L
Home Owner Address :S.ft0" Q--
Home Owner Telephone R • 22's — 5,
Present Mailing Address
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
Persons) 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 SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code
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