6 WILLSON ST - BUILDING INSPECTION 4 � t
�1 • 1 {
The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
n; Massachusetts State Building Code, 780 CMR, 7`h edition Building peps
Building Permit Application To Construct, Repair, Renovate Or Demolish a
(\ One- or Two-Family Du ening
tel„ This Section For Official Use Only
Building Permit Num Date Applied: 3010
Signature:
Building Commissioner/Jtp&for of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Propejty Add�ess s�-t 1.2 Assessors Map& Parcel Numbers
-1.1a 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 R) Frontage(R)
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.40,§54) 1.7 Flood Zone Information: L8 Sewage Disposal System:
Public Private❑ Zone: _ Outside Flood Zane?Check iTes❑ Municipal On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2^l r�Tvi Crvi I`f rP l j l t/PmF /W 4l 70
Name(Print) Address for Service:
� L r171-7�10— X34
Signature — v Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied)r Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify:
Brief cription of Proposed Work=: /7 r
P / S
P t
SECTION 4: ESTIMATED CONSTRUCTION COSTS 4- S 15
Item Estimated Costs: 011lelal Use Only
Labor and Materials
1. Building b 26LOO OO 1. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard Ciry/Town Application Fee
❑Total Project Cast (item 6)x multiplier x
3. Plumbing E 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No._Check Amount: Cash Amount:
6.Total
/Project Cost: S2C0'6 v0 ❑ Paid in Full ❑Outstanding Balance Due:
ir
�� c r
7-75-
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
N�mc of CSL-jlpldrr List CSL Ty
(xe below)
Address
T" Description
U Unrestr (u to 35,000 Cu. Ft.)
Signature R R s acted l&2 FamilyDwelling
M ason YO
Residential Roofing Covering
Trlep WS Residential Window and Siding
SF Residential Solid Fuel Buming Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Regisn ante Registration Num
Address
Exp; stion Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSU FFIDAVIT(M.G.L.c. 152.4 25C(6))
Workers Compensation Insurance affidavit a completed and submitted with this application. Failure to provide
this affidavit will result in the denia a Issuance of the building permit.
Signed Affidavit Attached Yes .......... 0 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: O ERt OR AUTHORIZED AGENT DECLARATION
1. , ,as Owner or Authorized Agent hereby declare
at the statements and information on tl oregoing 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:
1. 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 I O.R6 and I I O.RS,respectively.
2. When substantial work is planned, provide the information below:
Total floors area(Sq. R.) (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 Square Footage"may be substituted for"Total Project Cost'
CITY OF SALEM
^\•.�;y PUBLIC PROPRERTY
DEPARTMENT
Iii v'3.V;.);,;; X. 'j78 -4:
Construction Debris Disposal Affidavit
(MlUircd for all demolition and renovation work)
In accordance %�ilh 'thc sixth edition ofthe State Building Code, 780 CMR section 111.5
Debris, and the provisions of.1AGL c 40, S 54;
Building Permit h is issued with the condition that the debris resultin.- 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:
C d
(namc uChuller)
I he debris will be disposed of in
l?
(nwnr u(lacility)
l uddres, .d l ac;l I v l
agna WlC nt prnnn .yipl; t
late