50 BELLEVIEW AVE - BUILDING INSPECTION ' The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7" edition OF SALEM
Revised Junurrry
,I Building Permit Application"Ib Construct, Repair, Renovate Or Demolish a 1. 2008
One-or Ttvo-Familt,Dwelling
Th' ction For Official Use Only
Building Permit Number: Date Applied: Zr?
Signature:
Building Commissioner/Inspe or o K ui ings Date
S CTI N 1:SITE INFO&MATION
1.1�bOpe�ye Ilflress: 1.2 Assessors Map& Parcel Numbers
L la Is this
laan accepted street'9 yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
T
Zoning District Proposed Use Lot Area(sq 11) Frontage(fl)
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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check ifyes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record: / dW .P� 5 m�C6e al1�
/G 8 � CJ [S C Z7 t/L
Na Print) Address for Service:
igna[ure Telephone -
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)-
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition Cl
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Dea/�r�ipJtion of P7poscd Work': - ^ ,r� .p
d-/ , /)�V e I-UyN% V G o w l e 1. c T-cLl C
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: $
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
70 Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ d -' 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number pimnon)aale
Name of-CSL-I folder List CSL Type(see below)
rype Description
Address U • Unrestricted(up to 35,000 Cu.H.)
R Restricted 1&2 Family Dwelling
Signature N1 Nlasonry Only
RC Residential Rooting Covering
-1'elephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
1-IIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Dale ,
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
q� (� - / p Gt/� 't%i> as Owner of the subject property hereby
authorize I� '/ O— S (/.5 to act on my behalf,in all matters
relative to wo�horized by this building permit application.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
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 Cains and penalties ofperjury)
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 not 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 I IO.R6 and I IO.RS, respectively.
7:-When work is planned,-provide intormation 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"
CITY OF S.u.B.tit
PUBLIC PROPERTY
DEPART TENT
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HOMEOWNER LICLNS6 E XE.MPTIO,
Please Met
pAN I L�
Job I,«.tices S—d /3e/ee�,rcw
Ham Owner Address s
Home Owner Tolepbmw C> 3
Present Mailing Address
The current aamption o!"Homeowners"was extended to include owner-occupied
dwelUnp of taro Units or leas and to allow such homeowners to enpp an individual for
hire who.dodo not possess a Beam%provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Person(s) wbe owns a parcel of land on which he/she resida or intends to re dde6 on
which them is, or is intended to bs6 a one or two 6milr dwelt& 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
Imaeowner'shell submit to the Building OQleial,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 undenigned "homeowner'certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
.vill comply with said procedures and requirem
TU
HOMEOWNERS SIGNARE y
.APPROVAL OF BUILDING NSPECfOR
Sce other side for state code
Pools USA
37 Lambert Street, Revere MA 02151, (781) 286-3069
Installation agreement between Pools USA herein called tjwtnst4er and ke. ip*a
Herein called the customer of the real estate locat t w LL(. )-��n 1 dl m iC
r the ins ation of one swimming pool size _base installation price�r_0 purchased from
consisting of the;following: fence deck walkway
brackets etc. RL442/1,3
In order to maintain the lowest possible installation price,the following conditions m t be agreed upon.
1. The installer warrants the pool installation against defects in workmanship for swimming season(s)(season ends Dec 31°)
2. Installation does not include electrical work,stairs,ladders,or solar/heating systems.
3. All empty boxes and pool packaging are to remain at the pool site,at a location chosen by the customer.
4. Installer is not responsible for removing sod,rocks,dirt,etc.remaining from the excavation or for damage to the grounds resulting
from the normal use of equipment.
5. Customer is responsible to comply with any local zoning ordinances and to obtain any necessary permits and
specifically assumes sole responsibility for the exact location of the pool.
6. Customer is to stake out pool site.
7. Customer is to make sure pool site is not located over any underground services,leaching fields,septic tanks,etc.Any damage
done to the aforementioned will not be the responsibility of the installer.
8. Landscaping is not included in the installation,nor is the installer responsible for any alterations to the landscape.
9. Customer is to supply hoses,water to fill the pool,and accessibility to the pool site for any equipment that is needed.
10. All efforts are made to remove wrinkles from the liner.However,due to the prefab nature of aboveground pools,weather conditions
and other factors,WE DO NOT GUARANTEE A WRINKLE FREE LINER
11. The installer is not responsible for any manufacturer's defects including the liner and any results of that defect such as water loss.
12. Decks,fences,and accessories are not included in the normal base installation price.
13. For your safety,this is a non-diving pool.Customer assumes full responsibility to make all users aware of this fact,
and assumes any liability which may result from misuse of this pool.He/She also agrees to make sure signs indicating
"NO DIVING"are affixed in a conspicuous place and remain in good condition.
14. The installer is not responsible or liable for any damage to the pool or for a washout of the cove inside the pool due to poor
water drainage surrounding the pool area caused by rain,flood,acts of God or any types of storm,emptying the pool of water
or failure to winterize the pool.
15. There will be an additional charge if the pool base cannot be delivered to the pool site or if other than normal conditions exist.
16. The installer will not guarantee an appropriate fit between an existing deck and a new pool
17. The pool base may arrive without notice.Please leave driveway clear if no one is to be at home.
18. Dates of installation are subject to change at the discretion of the installer due to weather conditions or installation delays.
19. There will be an additional charge of$25.00 if your bank maims your check unpaid.
20. The installer is not responsible for missing pool parts.
Definition of a normal installation is as follows:Pool site within 6"of level,soil condition normal,no large rocks,tree stumps,etc.If heavy
equipment is needed,there will be an additional charge. If due to ground conditions the machine is unable to bring pool site to grade then
customer is to pay for services rendered and installer will discuss further options with customer.
The owner agrees with Pools USA in consideration of the performance of the above specifications to pay the contractor the total sum of
$ of which$ IX, has been paid this date�_/ and a$ FINAL CASH PAYMENT
is to be paid upon completion.
This agreement constitutes the entire agreement between the parties,and no other representations,agreements,or commitments are binding
upon the parties unless specified in writing in this contract. In witness whereof,we hereunto set our hand /_ .
COMMENTS: i�A le,il � f"Y (p �� !� // 2 gg17S —
1.;1.23 s.—
r /
ORIZED AGENT DATE CUSTOMER DATE