13 BELLEVIEW AVE - BUILDING INSPECTION -7 6
The Commonwealth of Massachusetts 'RECEW ERV,rp$
^n�yy Board of Building Regulations and Standard PECji0NA1 CITY OF
Massachusetts State Building Code, 780 CMP SA EiNI
!�
Building Pennit Application To Construct, Repair, Renovate 0"*Ns2a' ejt�All6r 2011
One-or Two-Family Dwelling
This Section For Official Us my
Building Permit Number: Date Appl' d:
-4"o 3~7 /
Building Official(Print Name) Signature Date
SECTION I:SITE INFORMATION
L1 Pro erttyy Address:AJe S �ern, MA 1.2 Assessors Map& Parcel Numbers
�3 ifW u
I.I a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: IA Property Dimensions:
zoning District Proposed Use Lot Area(sq f0 Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.t,c, to,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Z.one: _ Outside flood Zone'?Check if yes[] Municipal ❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2 Owner'of Re
T _t�,__tJ�O Gd�e
o
Name(Print) City,State.ZIP
No,and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
!Demolition
w Construction ElExisting Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ rVddition ❑
❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work" L t
on w; er✓ frdn�7 i ��rt ----- —ct —
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated CosJ2—
Official Use Only
Labor and Mate Y
I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ Other Fees: S
d. Mechanical (I IVAC) $ List: /
5. Mechanical (fire
Suppression) $ Total All Fees: $_
Check No. _Check Amount Cash Amount:G. Total Project Cost: $ 3 g00 ❑ Paid in Full ❑Outstanding Balance Due:
T
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
t 'T 9%r!t
License Number Expiration Date
Name of CSL Holder
' ),� ►Qj List CSL'rype(see below)
No.and Sneet Type Description
U Unrestricted(Buildings Lip to 35,000 cu. ft.
R Restricted M2 Family Dwelling
Cityrrown,State,ZIP M Mason
ry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(111C)
HIC Registration Number Expiration Date
HIC Company Name or FIIC Regislrm[Name
Nu.and Street
Email address
City/Town, State,ZIP "role hone
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
I, 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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in lh' application is true and accurate to the best of my knowledge and understanddiin/g.
/ZY 20JL
Prin )iwter's or Authorize)Agent's Name(Electronic Signature) 777 Date
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 Llome 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 LIIC Program can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.rnass.eov/dns
2. When substantial work is planned,provide the information below:
Total Floor area(sq. ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. If.) _ Habitable room count
Number of fireplaces_ _ Number of bedrooms _
Number of bathrooms _ Number of half/baths
"Type of heating System Number-of decks/porches_
Typeofcoolingsystem Enclosed ---Open-- -
3. "Total Project Square Footage"may be substituted for"'Fetal Project Cost"
AIL--- -_
L
CITY OE S�UENf, NLUSACHUSETTS
1 BLLMLNG DEP.11t'IlIENT
m
130 WASHNGTON 5 TREET, 3 FLOOR
TI !L. (973) 745-9595
ICIMBFIRr cY DRISCOLL FA--v(978) 7-W-9844
&LAYoa 111-10.%LAS ST.PMgjM
DIRECTOR OF PUBLIC PROPERTy/BCILOLN(; COJL\t155[ONER
Construction Debris Disposal Arfidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section It 1.5
Debris, vtd the provisions of IbICL c 40, S 54;
Building Permit 0 is issued with the condition that the debris resulting from
this work shall be disposed of in a property licensed waste disposal facility as defined by NICL c
I 11, S 150A.
The debris will be transported by:
y S��I � cello
(name utllauter)
The debris will be disposed of in :
(n;unc of Faclli )
—_---(jdJ—IC ssotriI-el Iit/)
I
SISIW turea pe, lt.Ipp lie J I It
�.IIC
CITY OF SALEM, MASSACS-IUSETTS
BUILDING DEPARTMENT
' h 120 WASHINGTON STREET,31D FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KINMERLEY DRISCOLL
MAYOR TrIOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONMSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date
5 z9 z6�
A
Job Location /3 U,r,� -loc &4le 51 %-,�?(>
Home Owner Address
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 that 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, 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 understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR
t,t ei
t( �i
ATI IL
Ig
Wl
r
Ay
i
»1. P m . ,
YY. .
._�
r r
,r