11 BELLEVIEW AVE - BUILDING INSPECTION The Comniom%calth of Nassachusetts
t Board of 131,111ding Regulations and Stand:uds It )R
NII NICIll-
1.' v° Massachusetts Slate Building Code, 78I1 lAIR. 7°i edition �I[
'r R, i iwd lawman a
� l3uilding I'Crmit :Application To Construct. Repair. Renovate Or Demolish a
Orle- or Tnu-Fumilr Darrllin,q 1. 'atrr,�' �
phis Section For Official Use Only
Building Pei mit Nun ec Dare Applied:
o-
Siulatule -\ O�
Budding Cornnusswned Inspe'nar of 13wldwgs Date
SEC"I'ION 1: SITE INFORMATION _
1.1 Proper(, \ resss: 1.2 Assessors Map & Parcel Numbers
I.la Is this:an accepted street.' ves_✓ no_ Map Numher P:ural Nwnhcr
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot .\rea(sq it) Frout:age ttia
1.5 Building Setbacks (ft)
j Front Yard Side Yards Rear Yard
Required ho%ided Required Provided Required Pnnidrd
1.6 Water Supply: (M.Q.L c 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone., Municipal ❑ On site disposal sy sicna ❑
Public ❑ Private ❑ Check il'yes❑
SECTION 2: PROPERTY OWNERSIIIP'
2.1 OrneraofRe�coArd: //,, lePv/e,--) o
Nam (Print) _ Address aor Service:
uC gOp 0 3
Si enatu re Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ E.x fisting Building Owner-Occupied Repairs(s) ❑ Alteration(s) El Addition ❑
Demolition X- Accessory Bldg. Number of Units j Other ❑ Speedy: _
Brief Desci rtion of Prupuseu`.���V,\ork-. --
—vim /rl1�t�'s'ice /s T' /�I!!ti/nN ��76�p'G�i/z 0�5Mnt/G
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
(Labor and Nlatzriulsl
I. Buddine $ I. Building Permit Fee: S Indicate how fee is determined:
2. Standard City/Tuwn Application Fee
Electrical S ❑ rotal Project Cost' (Item 6) x multiplier x
i
3. Plumbing S _1. Other Fees: $
J. Mechanical (HVAC) .S List:
5. Mechanical (Fire 5 /'
5u>>rzssion) rolal All Fees: S
Check No. Check .-Amount Cash Amount
j b. Total Project Cost: aid an Full ❑ Ourstanding B al:mce
F"
SECTION 5: CONSTRUCTION SERVICES
5.1 I. licensed Construction Supervisor ICSIJ
License :N'umber bxpoallon Date_.
.Name o(CSL- holder
L.nt C'SL Tope (See he low)
\ddI e's
'fv x DcseI i on
C Ilnrcstriaed nipm?5.(N)O('u. Ft.r
R Resumed I\_' F:uml\ D%,elhne
Signature V1 Masunn Only
RC Residential Roollne ('oven nY
Telephanr \\'S Ilesidrnn,tl \l'uido\, dad tiulme
SP Rc,vdrnu:d .S"Ild Purl Bumm" A >>li.tn. In.l.ill.utm
D Rcsidcnu;:l Demolmon
5.2 Registered Monte Improvement Contractor 011C)
111C Company Namc or IIIC Registrant Name Regutrauon Nuunho
Address
Expiration D:ue
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 prowidc
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
OW ER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1. OsUF1-LD /�L �fC�r`� as Owner of the subject property hereby
authorize to act on my behalf. in all maueis
relan to work authorized by this building permit application.
Swiatme of Owner Date
SECTION 7b: OWNER' ( 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 wins and penalties of erLrv)
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 (FIIC) Program). will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important intln'mation on the MC Proguan and
Construction Supervisor Licensing iCSL) can be found in 780 C NIR Regulations 110.R6 and 110.R5, respecti%ely.
' When substantial work is planned, provide the information below:
Total floors area tSq. Ft.) (including garage. finished basement/attics, decks or porch)
Grass living urea iSq. Ft.) Habitable room count _
Number of fireplaces Number of bedntorris
Number of huthrooms Number of half/baths
'I'vpe of heating_ system Number of decks/ porche.s --, _-----.
7'We of cooling System. Enwlused open
3 "Total Project Square Footage" may be substituted titr "total Project Cost-
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
'CFI:978-745-')595 )78.74,-9846
Construction Debris Disposal Affidavit
(required for all demolition lid renovation work)
in accordance with the sixth edition of the State Building Code, 730 CN1R section 111.5
Debris, and the provisions of IIGL c 40, S 54;
Building Permit p _ _ is issued with the condition that the debris resulting from
dais work shall be disposed of in a properly Licensed waste disposal facility as defined by MGL c
I 11, S 150A.
The debris will be transported by:
Se/ buy) g l� - GYee le rj
-- �thauler)
Hie debris will be disposed of in(name ur IuaLcy)
21 S'Y �ry�
CITY OF S.0 EM
PUBLIC PROPERTY
DEPARTMENT
KJ?01��Kw-n
MAYM I M WASUN[ZC H SMLM•SALEK S(ASIA01l•56M 01970
TEL 974745-959S• FAX 97L740.9&16
HOMEOWNER LICENSE EXEMPTION
Please Print
Dated! -/ _ G
Job Location // //e yr eu� S J4 Le ,
Home Owner Address L/ W Jeu) R27 ,< "4� irv,
Home Owner Telephone 9-29 7 SST
Present Mailing Address It
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.
DEFINMON OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on
which them is, or is intended to be,a 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 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 an equirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code