24 CLIFTON AVE - BUILDING INSPECTION (6) y� The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
/vv Massachusetts State Building Code, 780 CMR SALEM Revised Mar 2011
Building Permit Application To Construct, Repair,Renovate Or Demolish a
One- or Two-Family Dwelling
This Section For Official Use Only .. -
Building Permit Number:" Apr'x
Building Official(Print Nam �g re "t Date
SECTION 1: SIT F N;
1.1 P op fly.y dress: . Assessors Map&Parcel Numbers
iY4 � i Avg �33-o7a7 o
1.1a Is this an accepted street?yes no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
1 -7361, 6�{ 511
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(It)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Wale Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public Private❑ Check if yes❑ Municipal On site disposal system El
'SECTION 2 PROPERTY OWNERSHIP'.-
....
2.1 Ow eri o Rec rd:
r1 �c e ��;�le :,l �vm A . b j1'7o
Name no�tj City,State,ZIP
a� lilr F�n Ayc �78 ��1�15773 �vhur���1� 1106-c
No.and Street Telephone Emaili ddress
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)'" •"
New Construction Existing Building❑ Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition M, Accessory Bldg. ❑ Number of Units Other Specify:
Brief De cription of roposed Workz:
SECTION 4.ESTIMATED CONSTRUCTION COSTS' .. ry' "
Estimated Costs:
Item Labor and Materials I ,. OfficiafUse Onlg �,, =
1. Building $ op 1 Building Permit Fee $ Indicate how fee'is determined:-
2.Electrical $ ❑ Standard City/Town Application Fee `
❑Total Protect Costa(Item 6)x`multiplier
3.Plumbing $ 2.�Other Fees. $
4.Mechanical (HVAC) $
List "
5. Mechanical (Fire $
Su ression !� Total All Fees: $ ..
Check No Check Amount. :Cash Amount
6. Total Project Cost: $ p0 .❑paid inFull� ❑ Outsttandin Balance Due:,
3.65o Y �> g
r
i
SECTION5: CONS TRUCTION SERVICES` � r
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
T e `Descntron
No. and Street 8 yp. �;. .
U Unrestricted(Buildings up to 35,000 cu.ft.
City/Town, State,ZIP R Restricted 1&2 Family Dwelling
M 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 Company Name or HIC Registrant Name HIC Registration Number Expiration Date
No. and Street Email address
City/Town, State,ZIP Telephone
`. --SECTION6: WORKERS' COMPENSATIONINSURANCEAFFIDAVIT,(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 Issuanc of the building permit.
Signed Affidavit Attached? Yes .......... No ..... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
'DOWNER'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,xORAUTHORIZEDAGENTDECIARAT)ON
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 accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
M NOTES . u f
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.rrrass.aovr'oca Information on the Construction Supervisor License can be found at www.mass.eov/dps
2. When substantial work is planned,provide the information below:
Total floor 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"
1
: b CITY OF SM.E i, iNLASSACHUSETTS
BUILDING DEPART MNT
130 WASHINGTON STREET, 3Ptl FLOOR.
TEL (978) 745-9595
FAx(978) 740-9846
KI,\IBFut EY DRISCO[1
MAYOR "hi01tAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG CO`WISSIONER
* 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 c 40, 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 disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
( ,/f
name of hauler)
The debris will
be disposed of in
(L
1 I (name of facility) v
(address of facility) l --
kle'll of permit applicant
.20, oZ0l3
date
CITY OF s.kL,E.tit
PUBLIC PROPERTY
DEPART:,IENT
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HOMEOWNER LICENSE E.X1.NMj0N
?feu" Mat
Dail
lob LoeadM C/, K&-r, , AV e
Home Owner Address _ S a
Home Owner Telepboa/ 9 7? -7 y y S 7-7�
Pretend Mailing Address
ids current exemption of"Homaownere was extended to include ownar oeeupiad
dwellings of two Units or less and to Wow such homeowaes to engage an individual for
him who does not possm a lieenso provided that the owner acts M supervisor.
DEF1NM0N 0I HOM80WM
person(s) *be owns a pnital OINW on which hdshl resides or intends to resid/► on
which there i6 or Is intended to b46 a on/.or two family dwelling attuhed or daubed
statue$ accessory to.such use and/or farm structures A parson who comtrucu more
than on"home in a two year period shall not b"coadderod a homeowner. Such
"homeowner"shall submit to thi Building 0Qlci4 on a form aecsptabls to the Building
Otllcia0, that hdshe be responsible for Al such wort performed under the Building
Permit
The undesigned "homeownea"a nines responsibility forcomplianc"with the Stet/
Building Code end other applicable byalaws and regulations
The undemired "homeowner certitles that he/she undentands the City of Salem
Building Department minimum inspection procedures and requirements and that hesshe
.vi11 comply with raid procedures and requiremen
HOMEOWNERS SIGNAIZ.'RB
.APPROVAL OF 9UILDIVG MPECTOR
See other side for state code