5 CEDARHILL RD - BUILDING INSPECTION Fhe Commonwealth ul %IdS,aehuset1S
_. Itrlt
� I3uurJ of I3uIIJing Krculalions and Standards
%1a„e.huScns SIWr Building ( ode, 7S111''11R. 7 eJitlt n I �I
j .. , . r , t Reno% Ice OI Delnl Jl,ll a ll� � r„ •l lnrr,u
(� I IfuilJin� Io mit .\p�lication To ( t n. Uuil. Repoi
V Otte or Tito-/tofu i Oo, Nille
-- —
1 his Secotrn [:or Offii lal l`sr Only -- ----- ~
^� n __-- e p uBuJJu,g Perul Nam r _ ) \ J _ Z♦�I _O_16
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Build ig Comm n.nrne❑ Inspe.tor ul Building, Dale ._ .
.SE(TION I: SITE INFORM:ItHON
j 1.1 PJo er AQ/n ( 0 1 1.2 Assessors Nlap & Parcel `umbers
' \ C -__ _ . ._-_.{_--_d—_.-_ \Lr \umhrr I'.u.rl Xwnhrr
I I I ! Ihs an uevelxed street" �e.__ lilt— P _--
r1.3 "Zoning Information: 1.4 Property Dimensions: i
'r •• Pn.e:':.;d i ... I_ :r ::rea1W 111— ._.__—___. FrwtWge ill s_-._.__.__ �.- j
?I ' Buiitb...; Setbacks (ft) --_
j Front Yard Side Yards Rear \aid
Reylcd 1 Provided RcyuucJ Pro%;ded R:yuu rJ T i'o„rdcd
m
' I
r16W'aler Supply: LN.G.L c 10. §S 1) 1.� Fiood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone' Yh,mnpal ❑ On site dislw+,al svdcnt ❑
c❑ Pit cafe ❑ Check If yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1/Q;nler�clReygrdLoetcla, J C " Ft[l� � —
X =xnPrii r lh' U Address 1'ur Service
Swrlonure Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied x I Rep:un(,) ❑ :\I:eranon(,) ❑ :\JJun a, ❑
Demolition ❑ Aci:essoiyB1dg,.A Number of Units I Other ❑ Sp,,,ly
Brief Descript on of Proposed Work': -
SECTION 4: ESTIMATED CONSTliUC IONICi9-iTS ---
kern Esuma(ed C biS: Official Use Only
(Labor and Materials)
1 IiwlJn,e 5 1. Building Permit fee: 5- InJlCate how fee is Jeler mined.
I— - ❑ Standard Ciiy/fown :\ppheatlun Fee
2, Heetnral 5 ❑Total Project Cosi' Mem 6) x mulhplicr x
7. Plumhmg 'S _'. Other Fees: S
1. NItehamcal IH\':\CI i 11.rt: 1 x���_
\Iechame,l IFIrc
fo(.II All Fee,: 5 __
Cheek No __('h .\m eck �at rn m -.. l�.nh \rrunt
X b total Project Cusl /� d o ❑ Paid In Full 0 l)u1,t,mJln„ Bal.ul,c l)ue
SECTION 5: CONSTRIL L (ION S1-'R ICF S
;.I Licensed ('oiistructioiiStipersisi)riicSi.;
I Is( l S I I1Ix •c h,
I II, o,I .,I t H it k
R0,111,!Cd IN' lal...It
+
M %la"mrN t)11k
I R( R,%,rme CI I'll,
T11d 'l J: _,
H. d,I, I S, I j I I I I,.; T,
.uli.il 1),[Till, 11-11
5.2 Registered I lonte Improvement Contractor i HIC)
I(CLI,II anon Nuiuhcr-. -
tjjjjIja,jl N,,111c oI III(' Rcuisituot Name
lelcphone
SECTION 6: WORKERS' CONIPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. 2506))
Workers Compensation Insurance atticlavil inuNt bec,,nipleted .1od 'Uhnimed with this F.ol Lire to pis„ide
this atf-idavil will result in the denial (it the Issuance of the building permit.
Signed Affidavit Attached? Yes ....... .. 0 'No 0
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the tihj�ct po,pett) hereby
all thi., ze to "L I I lo M.N r1l htd 1. 61 al: mallet S
;e!.:tj%e to %kork authorized by this building permit application.
SiLpiature or Owner Date
SECTION 7b: O"NEWOR AUTHORIZED AGENT DECLARATION
I. as Owner orAuthmi/ed \,,en( heich} Jeclao:
that the statements and m6ormationon the loregoini: application are (rue and accurate, to the best or my know1cdLC
behalf.
Print Name
STinature Lit Owner or Authon/edAtvem Date
(S'2gried under the pains and penalties of PCULiry)
NOTES:
I. Nn Owner ��h( ins in d his/he n work h 'e, ,,�,cd ,LooI, L I
.r who
III r ooZ
t L la a buildto o r"w "r owner
e L e I r.cj�l I Program).
ro(2 e �ILL , to the o 'n ot
Lit registered
- 1710 ��irnmnt ( till r (111( gram) will ff�l ha
�r d in the 11171"
program
1 1 or
va r I to r G.L.0
L Jl� L t)l ijortart
in a in v fund under 142 A her rin intot matron n the III( I . ... ...I
When substantial work is planned, pi,n ide the intoornation below
F,nal Visors area I Sq. Fr i i including garage, finished hacment/ani,N. decks ,r pL-iJi,
(iio,, Imm, mea 1.Sq. Fr.) Hahnoble n,om o,unr
Numberct tociflaces—__ Nomher M hedrt,L,(Ti,
Numher of hatin,L,-in, NLImhcrot h.ilt
I we ,q heA1111V N,tern Number,-r dc,k,, 11,-1
I %Ile or 'cd
Po�je I I l.,(al Pn,jeci SLILI,Ifel'�1�11,11'e Ile Itill'JOUted tLIF '(A
CITY OF S.0 EM
PUBLIC PROPERTY
DEPARTMENT
71n.TW745-9"S*FAX 972-740.9646
HOMEOWNER LICENSE EXEMPTION
pies"Prlit
Date
Job Location S CC-
Horne Owner Addre"
Home Owner Telephone
Present Mailing Address S C e t I^11 I
The current exemption of"Homeowners"was extended to include ownw-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.
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 dwellin& 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 and requirements.
HOMEOWNERS SIGNATURE �3f
,APPROVAL OF BUILDING INSPECTOR
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See other side for state code