6 GALLOWS CIR - BUILDING INSPECTION /LO The Commonwealth of Massachusetts
wn of
Board of Building Regulations and StandardsA*w0owkes
tJ .Massachusetts State Building Code, 780 CMR, T"editionBuilding
Building Permit Application To Construct, Repair, Renovate Or DemoliOne- or Tuo-Fartith Di ellinis lion For ORci I Use OnlBuilding Permit Number: Date A lieMnib
Signature: /uildingCommtssto /InspectorofBud gs� DateISECTION I: 1 INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel1.1 a Is this an accepted street?yes no Map Number I.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed UseLa Arcs(sq R)I.S Building Setbacks(h)
Front Yard Side Yards Required Provided Required Provided Requd
1.6 Water Supply:(M.G.I.c.40.154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es0 P
SECTION 2: PROPERTY OWNERSHIP'
2. Owner of Recor
Name(Print) Address for Service:
Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O 1 Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
BniDescription of Proposed Work'
IC,e �ao
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
1. Building f 1. Building Permit Fee: f Indicate how fee is determined:
❑Standard City/Town Application Fee
Z Electrical f r❑Total Project Cost (Item 6)x m5;a�
1. Plumbing f Z. Other Fees: f4. Mechanical (HVAC) S List:
s Mechanical (Fire S Total All Fees. f
Su ression
�O Check No. _Check Amount: Cash Amount:_
6 Total Project Cost: S 300zD ❑ Paid in Full O Outstanding Balance Due:
r< ,
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
1-wense Number Esptration Date
Nyoe ot'CSL HylJer List CSL Type(,cc below)
Address T Description
U Unrestricted(up to 35,000 Cu. Ft.
R Restricted Ih2 Family D%elhn
Signature M --tasonry Only
RC Residennal Roofing Coverm
Telephone WS Resrdential Window and Siding
SF I 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 Date
Signature Telephone
F
CTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 25C(6))
Compensation Insurance afdavit must be completed and submitted with this application. Failure to provide
vit will result in the denial of the Issuance of the building permit.
frdavit Attached? Yes .......... O No...........O
N 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
o t,L-Vn- �—�o e�� , as Owner of the subject property hereby
C c^�s�.�ro r� r�x�a _ _ _ to act on my behalf,in all matters
work aut�horiz by this building permit application.
Signature of Owner Date
SECTION 7b: OWNER'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 pains and penalties of perjury)
NOTES:
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 W 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 110.R6 and I IO.R5. respectively.
2. When substantial work is planned,provide the information below
Total floors area(Sq. FL) (including garage, finished basemenUattics,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 deckv porches
Typeof cooling system Enclosed Open
3 "Total Project Square Footage'may he substituted for"Total Project Cost"
A
CITY OF S U.E.NI
PUBLIC PROPERTY
DEPARTmNiENT
,."....
MA106 tie WMNP1 "9ns►t 9 sw.na Hws ACHLSW nO19.0
iaL r.L715-95"• Eut 97e.7449&4
HOMEOWNER LICENSE EXEMPTION
Please Print
Date Q-\ oin - 0c,
Job Location ( , CDC `\,n U S C i ?
Home Owner Address S ri- . e
Home Owner Telephone G'a Sr `� WC- 2 C, u -
Present Mailing Address P _
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
hire who.does not possess a license,provided that the owner acts as supervisor.
DEFIIYITION OF HOMEOWNER
of land on which he/she resides or intends to reside,Perso s who owns a parcel de, 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 more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building OlHcial, on a form acceptable to the Building
Official, that heJshe 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 L I
APPROVAL OF BUILDING INSPECTOR
See other side for state code
I
CITY OF SALEM
� i PUBLIC PROPRERTY
DEPARTMENT
120 WASI IING 1 ON SD(LET •S.\I F.M.MAST%( i It SI.I'i
'fEL 978-74 9i95 • FAX:978-740-9846
Construction Debris Disposal Affidavit
(required 1'or 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 he disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
Uaamt,of hau erf)
The debris will be disposed of in
N 'D 2Z �„
— �1 _Z � CG 2'1-•��
(name of facility)
(address of facility)
signature of permit applicant
date