10 BELLEVIEW AVE - BUILDING INSPECTION r
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
y ) OF SALEM
Massachusetts State Building Code, 780 CMR, 7ih edition
i Revised Jueuury
n Building Permit Application To Construct, Repair, Renovate Or Demolish a /. '
One-or hvo-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
r'
Signature: ''.!=� U
Building Commissioner/Inspectorof Buildings Date
SECTION 1:SITE INFORMATION
1.1 Prop�eC�ty�Address: I / 1.2 Assessors Map& Parcel Numbers
I.l 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.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewagee/Dhposal System:
Public H Private 13Checkif esZone: _ Outside if Flood Zone? Municipal H On site disposer system 13
SECTION 2: PROPERTY OWNERSHIP'
2.1HAleA�l tftew% C CA- i-02- /C� ,�E�ra=✓lLS�J �/
N mN m (Print) Address for Servi���
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Cl Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work 2:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Ofllclal Use Only
Labor and Materials
1. Building S I L Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing S 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: S ❑Paid in Full O Outstanding Balance Due:
a�� L) / 7
r
R �
s
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name ol'CSL-Ifolder List CSL'rype(see below)
'r Description
Address U unrestricted(up to 35,000 Cu. Ft.
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC Residential Roofing Cuverin
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
1110 Company Name or 111C Registrant Name Registration Number
Address Expiration Dale
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 ..........O No...........O
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.
-Siwmum of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
'
1 I �(; ,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
behal
L-
P e S— � — 2010
Signature of Owner or Authorized Agent Date
(Sistried under the pains and penalties of 'u
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 nu.1 have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 IO.R6 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 Square Footage"maybe substituted for"Total Project Cost"
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CITY OF S.UY. Ni
PUBLIC PROPERTY
DEPARTMENT
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748-978-715.9599•F.wt 9'8-7469646
HOMEOWNER LICENSE EXEMPTION
Please Print
Data
Job Location 10 LLEV(EW Av
Home Owner Address 10 =WAV
Home Ownw Telephone
Present Mailing Address s
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,s one or two family dwelling, 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 wort 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
.1PPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SALEM
i PUBLIC PROPRERTY
�• DEPARTMENT
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Construction Debris Disposal Affidavit
(required fur all demolition vel renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit M 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 l I. S 150A.
The debris will be transported by:
mama ul hauler)
The debris will be disposed of in
(Ilium ul aci Ity
(address of l'x if ity►
%i/nature all pernut.tpphcaM
date