23 CLIFTON AVE - BUILDING INSPECTION t '
I'lie C s'nununtvcaltlt of NLISs;lihusclis
Ilo,trd of Building Regulations and Standards (- VY OF
�G '7 \Ltssachusetts State Building Code, 7SQ C'NIR `ALFM
'L,,•, He riled 16u 'll//
Building Permit r\pplicalion To Construct, Repair. Renovate Or Demolish a
(ble-or rllw-Pinnlll Unellin,\•
Phis Section Fur OIFI 'ui Uic Onl
Building Permit Number: _— DajiApplied: _
IIuilJiny()llicial(I'rinl N;unu) Silplaturc Oate `
SECTION I:SITE INFORMATION
1.1 Property lddrea: 1.2 Assessors Map S Parcel Number
oZ3 CIt_F_,6 Avg Sajan-�
I.Is Is this an acre led street?yei no Map Number Parcel Number
11.3 Zoning Information: Li Property Dimensions:
/aoo 4o
Coning District 1'nipuscd We Lill Area 04 11) Frontage(II)
1.5 Building Setbacks(R)
Frunt Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1.V.40.§54) 1.7 Flood Zone InformatlOni I.g Stwaga Isposal System:
Public 0 PHI ate O Inns: _ Uubide Flood L ?
Check if es Municipal Un sila Jispugul system O
SECTION!: PROPERTY OWNERSHIP'
2.1 gqwners of Record:
Rndrev ) Tcsrelsun CArl5fInR larfer Sa�crn, MA 019'10
Nana¢f Pant) (.ity.State.LIP
2.3 C'1-F{nn hvc- 7JLL3 t-a3 a+turc.�so du
Nu.and Sircet I dd rCde/'a_. m e„C e
rulephune Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) Alleration(s) Addition O
Demolition WFACcessory 111&O Number of Units Other O .Spccity:
Brief Description of Proposed Work': Ki cn reriow.,hof Ca rr R^' hia bor addlM
jsla d, demo l.e wal)s i Ilgh "K I new o�plf na,s/ na,s J
TT
SECTION 4: ESTIMATED CONSTRUCTION COSTS
hen! Estimated Costs:
I Labur;rod.\arterials) Official Use Only
I. Building S /O,D 00 I. Building Permit Fee: S indicate how tee is determined:
'. Hvctrical S /SO p ❑Standard City,Tussn Application Fee
❑Total Project C'ost'(!lens 6)x mulliplier _ x
J I'lunihing S IOOD :. OtherFees:
J. \fC01 llia.tI ill\ 1(') S List:._ _.___ __.-•�(J- !"—CJ. .
S11.4e Ulonl S riaal \11 FCC%: S
( hcck \') (-heck .\moiwt (',ish \uunuu:0 1'utal Project Cust: i Io�,S00 — -- _. .._. .
O P.lid in Full ❑Outstanding HaLmce Due:
r
SF.( I ION S: ('ONSI'RUCIFION SER1, 1( FS
T .1.1 ('onstrucIlot, Sullen isur I.ice nse 1('SI.) _
_ ion I Icen.e Nunlhcr _ .. ._. �isplrawm I>dlc
ha(z N,une,dl''it 110i1icr -- -
I Isll'SI. 1)pcl•cchelu,+l.._._-- .
--... -_—_ - f)Pa I)escriptiun
\Veet II IIIVnIriclCJ ll)uilJln a li IU 11,U1111.n. II,I
li He,IricleJ L'l?I .mail Do0 in
\I Mastiory
HC' Hlntli 1 Co%ehnil
µ'S µ'indaw alu Nuillil
SF Solid Fact Ilurning Appliances
( Insulation
1'ele ho11C 19naiI;IJJrcs+ D Dcnwlidon
4.1 Registered Hunts Improvement Contractor(HIC)
1IIC Itcgist—mlxr Il,piruiun IJaW
I IIC Contpin) MuTc or I IIC lwalstrum NJole
I:ITaII aJJresa
At. No. and Steel
Ci !Town, Stnte ZIP T& one
SECTION 61 WORKERS,COMPENSATION INSURANCE AFFIDAVIT(M.G.L C. 152. 2SC(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this atlldavit will result in the denial of the Issuance of the building pe 't. 1
Signed AlTldavit Attached? Yes .......... No..... ..... ; I o 6c a X c r� ^) Pain urja•
TO 0
OWNERS AGENT OR CONTRACTORTION APPLIES FOR BUILDING P RN IT
I, as Owner of the subject property,hereby authorize Ch4,1; ., par4u ( Wj}
to act on my behalf,in all matters relative to work authorized by this building permit application.
�A(, Tint-ko� 7- 11-1Z
Date
Print Uencr`s NulTe(Elecwnlc Slynuture)
SECTION 7b: OWNERa 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 ttrue and accurate to the best of my knowledge and understanding.
2—
naw
I'riW Uwncfi tar:\udnmred.1yem i Name Il.l.urunls Slynawnl
Nous1
I. .\n Owner who obtains a building permit to do his.her awn twrk,tar an owner who hires an unregistered contractor
(out registered in the Hanle ilding ement Cunt (HIC) Fragrant).will fro have access to the arbitration
program or registered
in t y fund under ovellL. c. 142.ntv Other important information on the HIC Program can be found at
nl.r.. " •', I Information tan the Construction Supervisor License can be found at-- Ill.n P
\\'hen subil:vuial,tuck is planncJ, provide the infun ition l Jinylwage. finished basement auics, Jccks or porch l
Raul flour area I<y. tl.l _ ---- - Habitable room wont
Gruislisingerealsy. 11.l _._ -
\unther of hcdroanls
I \unoher 11 h�ilrc rouill \umber of hall'hudli
\umhcr at halltrCJllli i
i)pc of he.Tutg ;),tcln \unlher I11 Jccki ponhci
6pe.'I c,�aling y,um
I'ncln,cJ _t)Fen
1 "I'� I.11 Prow \Ihl.lfe l'mgage I11a\ I'e ,IIh,11I11ICd lilr..l,dJl 'rUjvCt Co A'
l
CITY OF SAL&NI, AISS.ICHuSETTS
dLtLDLV(; OEF.gmwiT
I'O ')V- )iCVGTONSTREET, J"FZOOIt
lam. k918) 74s.9599
K130ERLAY OUXOLL F.I 074 1f4784s
N(AYOA MO-%W ST.?this
OIRUT04 OP PC atIC PROP1ATY1 at;Q,pL'4C COA01IStrON EIt
Canstruction Debris DISPOS31 Aflldavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Cad J
Debris, and the provisions of MCL a 40, S J4; e, 180 CMR section 111.
Building Permit M is issued with the condition that the debris resulting from
1 11, S 1 JOA.
1 work shall be disposed of in a property licemed Mute disposal fscility as defined by NICL c
I
The debris will be transported by:
(�SjfhaeduioU
an debris wi 11 be disposed of in
0amra or rudiry �—'
01drear art�ihiY)
fnJNlO Vr JClTIfJ _-
vvh�mr
CITY OF S.U-&Nt
PUBLIC PROPERTY
DEPARTMENT
w u„aa+r o�suaa.
VAvae 130WU USGU 1VIEW•SAtaA%VASAOMUM019V.
M ra7+5.1s" •VA&rt<7�69w
HOMEOWNER LICLNSE EXIM"10M
P1ew Met
Dots
lob Location a 3 /\,t A- O I Q -7 O
HomoOwoerAddrose $amp as Toh loci tan
Hama Owsoer Telephone 177 1- 1 - a 3
Peeled&failingAddtao Same as Tob Iota io
Tie current exemption of"Homeownere was extended to include owner-occupied
dwellings oltwo Units at leas and to allows such homeowners to eagags an individual for
him who.does not possess a licmaey provided that the owner acts as supervisor.
DEMMON OF HOMEOWNER
Persons(s) who owns a parcel olland on which bdshe resides or Intands to reside. on
which them ist, or is intended to bo,a one or two fail ily dwelling attached or detached
structures accessory to such use and/or rum struetnra. A pawn who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeownee shall submit to the Building OQlcial,on a form acceptable to the Building
Ofticial, that he/she be responsible for all such work performed under the Building
Permit
The undersilpted "homeowner"assumes responsibility forcompliance with the State
Building Code and other applicable by-laws and reguladons.
The undersigned "homeowner"certifies that helshe undentands the City of Salem
Buildin{ Department minimurn inspection procedures and requirements and that helshe
Will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF 9UILD NG NSPECTOR
See other side for state coda