24 CLIFTON AVE - BUILDING INSPECTION Z, The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7"edition Wilbraham
Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a 413-596-2800
1 One-or Two-Family Dwelling Ext 118
This Section For 00wiakusc Only
Building Permit Nu er: — Da S Appl ed: _
Signature:
Building Commissioner/Inspector of B. dings to
SECT ON 1: I FORMATION
1.1 Property Address: 1.2 Assessors Ma & Parcel Numbers
24 CI;> /ire P 33- 07a1-0
L l a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4—Prroperty Dimensions:
Zoning Proposed Use _ Cot ea(� Frontage(tt)
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 'one Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?
Public Private❑ Check if yes❑ Municipal Lyl'On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
M rhae� C�mIQ� _ _2d GII��n _
Name(Print) Address for Service:
1-78 74N 5113(W bn 791 838' /
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) ❑ AI[eration(s) ❑ 1 Addition
Demolition ❑ Accessory Bldg. ❑ Number of Um[s Other G✓Specify: 'AQIIQE- SjWe,
Brief Description of Proposed Work': Lt1Sk.lop_
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:
2. Electrical g ❑Standard City/Town Application Fee
❑Total Project Cost(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:__
5. Mechanical (Fire $ -
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 0 Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL Holder List CSL Type(see below)
Type Description
Address U _ Unrestricted(up to 35,000 Cu. Ft.)
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC 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 BUN,71,NG PERIMIT
1 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.
Si nature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1 �A,�- (R�� m ,as Owner or Authorized Agent hereby declare
that the statements and inforation n the foregoing application are true and accurate,to the best of my knowledge and
behalf.
M�cha�l � �-(nl,✓�
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the 2ains and penalties of eu
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. 142A. Other importani information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 IO.R6 and I I O.RS, respectively.
2. When substantial work is planned,provide the information 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.XLEIM
- PUBLIC PROPERTY
DEPARTMENT
Vwroa 13O W;43- RaN ME=9 SALEK MAZAna'SEr7S 01970
TEL 97a-7iS-9S" 9 FAX.978-740-9"
HOMEOWNER LICENSE EXEMPTION
Please Print
Date
Job Location a Oitb r Lie, . Sa�ei-n e MA-
Home Owner Address
Horne Owner Telephone Tr< a-p s?'; 4l (27 -79q RJUE
Present Mailing Address 2y c,i;f mr, Pwe. SgiUrrn 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 who does not possess a license,provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Persons) 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 mom
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
APPROVAL OF BU1LD[,YG LNSPECTOR n r�
See other side for state code