39 BELLEVIEW AVE - BUILDING INSPECTION (2)
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(n The Commonwealth of Massachusetts
(}U Board of Building Regulations and Standards FOR
" Massachusetts State Building Code,780 CMR, 7`s edition MIUSE 1Y v
Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Jonuery c-1
�J One-or Two-Family Dwelling 1, 2008 r
This Section For Official Use Only N
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Building Permit Number: Date Applied: t`'
4 r�9
Signature: •!�/ 1 7 12 KI
Building Commissioner/Inspector of B 'ldus Date -
SECTION 1: SITE INFORMATION N
1.1 Property Address: n�l 1.2 Assessors Map&Parcel Numbers
7P [/lt�i P) t1I/� � ir7T�
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
7Soaf� /Oa
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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 Sewage/Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal W On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSIIIP'
2.1 Owners of Record: J z 9 s-j 29e%/['r//ny fillp.
N e rint) Address for Service:
V 7(f- 3.3 ?7/y
rgnature Telephone
SECTION 3:DESCRIPTION OF'PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building 6 Owner-Occupied E( Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED C NSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 0 0 o 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 $ �(f 2. Other Fees: $
4.Mechanical (BVAC) $ 20 0 List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 3 -2 010 ❑Paid in Full ❑�O ding Balance Due:
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SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL-Holder
List CSL Type(see below)
Address Type Description
U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC Residential Roofing Coverall;
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential 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.§ 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 L5 m I n t S � 2 o pD yL o S as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative t work authorized by building permit application.
S a of Owner U Date
SECTION 7b: O`W_NEW OR AUTHORIZED AGENT DECLARATION
I, �S hn t h t S�7�-2.f0` c)(A I C�� as Owner or Authorized Agent hereby declare
that the s ents and information on the foregoing application are true and accurate,to the best of my knowledge and
behal ��_• �/„_
Print Name C +Or— 0tDo A Q S
=6 YI'l l n I v 1 r
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 110.R6 and 110.R5,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"may be substituted for"Total Project Cost"
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QT'Y OF SALEM, MASSACHUSE M
BUILDING DEPARTMENT'
120WASFIINGTONSTREET,38DFLOOR
L. (978)745-9595
KIMBERL.EYDRISCOLL FAX(978)740-9846
MAYOR THOMAS STAERRE
DIRECPOR OFPUBLICPROPERTY/BUILDING CONWSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT.,,
Date___7��'
Job Location�����t�����
Home Owner Address,_� pUie��
Present Mailing Address 'So/��-L-
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 proce res
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR
CITY OF SALEA,MASSACHUSETIS
BmDmDEPAR7MENr
120 WA9M4G7MSMWT,3WFLOOR
7kL(978)745-9595,
RIMRFRIFYDRISGbLL FAX(978)740-9846
MAYOR IkC MAS STJ'JEW
DmEcrcacFPUBucPRoFmY/BUS monmw Sfoi�=
Construction Debris Disposa/Affidavit
(required for all demolition and,.renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, S 54; Building Permit g is issued with the
condition that the debris resulting from this work shall be disposed of in a property licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
n of hauler)
The debris will be disposed of in:
(name cility)
(address of facility)
Signature of applicant
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