43 BELLEVIEW AVE - BPA 15-432r
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The Commonwealth of Massachusetts RECEIVED CITY OF
i Board of Building Regulations and StanddfP EC tICNAL 9E YIC EM
Massachusetts State Buildin ��
`�' "�'��� Revised Mar 2011
Building Permit Application To Construct,Repair,Renov sh - 3
One-or Two-Family Dwelling s'
This Section For Officid Ilse 0
Building Permit Number: Date Appliod:.
-Building Official(Print Name) Signature `
SECTION 1:SITE INFORMATION
1. Property Ad�ress: 1.2 Assessors Map&Parcel Numbers
f1V^Y\ � \\ . r,r �Qr �
L l a Is this an accepted street?yes v' no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
From 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 l9IOn site disposal system ❑
Check if yes❑
SECTION 2: PROPFATY,OWNER: ' '
2.1 qq"ertofRecoCad:
rd•
, li Sr�4L-VV% vv1J o N R-1 0
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PR Of VD WORTf?(check all that apply)
New Construction❑ 1 Existing Building EdOwner-Occupied Repairs(s) 9— Alteration(s) ❑ 1 Addition ❑
Demolition Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work :
SECTION''4:,ESTIMATED CONSTRTICTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
1.Building $ l 8S o•d 1. Building permit Pee:13 Indicate how Yec is nets hued:
2.Electrical $
Stand. '(5tyhow;Applir�tcn Fee
13 Total Project Costa(item 6)x multiplier x
3.Plumbing $ 2, Other,gees: $
4.Mechanical (HVAC) $ Listt
5.Mechanical (Five $
Suppression) Total All Fees:$_ _
Cheek No. Check Amount:_ _Cash Amount:
6.Total Project Cost: $ /b S O.'O O ❑Paid m Full Cl Outstandin Bolance Do
SECTION 5: CONSTRUCTION SERVICES
r 5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
Iy -List CSL Type(see below)
No.and Street - .-.. _ _ Type. Description
U I Unrestricted(Buildingsp u to 35,000 cu.ft.
City/town,State,ZIP"'--�_ -- I^1 R Restricted 1&2 FamilyDwelling
M I Masonry
' 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(HIC)
HIC Registration Number Expiration Date
Inc Company Name or HIC Registrant Name "
No.and Street Email address
City/own,State ZIP Tel hone
SECTION 6:WORKERS'COMPENSATION INSURANCE Aff TDAVIT(M.G.L.e.In-§25C(0)
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 AUTMOMU'hON TO BE COMPLETED WREN
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 OWNER 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 this application is true and accur to to the best of my knowledge and understanding.
Cox
Print Owner's or Authorized Agent's Name T sic Signature) ` Date
,TEST
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 can be found at
www.mass. oe v/qca Information on the Construction Supervisor License can be found at",w.mass.gov/dps
2. . When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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'
QTY OF SALEM, MASSAmUSETTS
BLUDING DEPARIwNr
120 WASHINGTONSTREET,YDFLom
TEL.(978)745-9595
KDOERLEYDRISCOLL FAX(978)740-9846
MAYOR THomAs ST131ERRE
DIRECTOR OF PUBLICPROPERTY/BUILDING CDj&ffSSIOMR
Construction Debris Disposal 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# is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
'F,aa— 6�-�
nature of applicant
Date
i vb�
QTY OF SALEM, MASSACHUSEM
BUILDING DEPARTMENT
120 WASHNGTON STREET,3AD FLOOR
TEL. (978)745-9595
FAX(978)740-9846
KIMBERLEY DRISCOLL
MAYOR THOMAS STTIERRE
DIRE CTOR OF PUBLIC PROPE RTY/BUILDING CO&MUSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date ,S 8 /
Job Location 4-3
Home Owner Address 4'1, Q%A\.�v.%_,- • (A' %r.A*,, 1M A
Present Mailing Address 5;gA* " MA
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.
V_
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSP R