3 GALLOWS HILL RD - BUILDING INSPECTION TI 6 Oct j a c/ * "r , / ,
Q The Commonwealth of Massachusetts
1. Bgard of Building Regulations and Standards Town of
p) � Massachusetts State Building Code, 780 CMR, 7'"edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a ItYomwYm
One. or Tuo-Fumilt•Dmrlling
This Section For Official Use Only
Building Permit Number: Date Applied:
Signature: O • O
Buddin ommissioner/Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Propert�dd�s� HJ J( �� 1.2 Assessors Map Qc Parcel Numbers
I.Is Is this an accepted street?yes 1 JT no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(it)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
// Zone: _ Outside Flood Zone?
Public❑ Private O Check if es❑ Municipal On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record^. f ✓-1 c° ' OL,-) &41 /*
rp
Na a(Print ti Address for Service:
92 t �
Signature Telephone
SECTION 3: DESCRIPTI OF PROPOSED WORK'(check all that apply)
New Construction D Existing Building W1 Owner-Occupied Repairs(s) ❑ Alteration(s) , Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units-12U I Other Cl Specify:
Brief Description of Proposed Work':
II�JS?W t. IACfy S6bLAfri�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S- I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: S
4. .Mechanical (HVAC) S List:
5.. Mechanical (Fire S
Su ression Total All Fees: S
Check No. _Check Amount: Cash Amount:
6. Total Project Cost: 13 Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) '
f—
'' Liceme Number Eipiraton Date
N:Imc of CSL- Helder
Lim CSL Type(sec below)
PDResi"Iedential
Description
Address
Unrest- u to J5,000 Cu. Fr)
cted 1&2 FamilyDwelling
Signaure Onl
ntial Roofing Covering
Telephone ntial Window and Sidin
ntial Solid Fuel 8umin Appliance Installation
Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 .......... O No........... O
SECTION 7n:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES EOR BUILDING PERMIT
1, ^1/., t�'.V�.�-- AD -3-7 e, as Owner of the subject property hereby
authorize to act on my behalf,in all,natters
relative to w au nzed by s buil g permit application.
Si nature of0wner Date
SECTION 7b:OWNEW 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 ofperjury)
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 MW have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115. 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
TYpeof cooling system Enclosed Open
3. "Total Project Square Footage" may he substituted for 'Total Project Cost'
.:y
1 is
" CITY OF S.U.E.vI
PUBLIC PROPERTY
DEPARTMENT
�..rc��r1l,yw•n L
yAVG@ t 30 wAgw4GmN SrtEzr 9&A,a- %&.uAon'serrs or970
14i 9'.L7319S"9 Fnx 97e•740.9846
HOMEOWNER LICENSE EXEMPTION
Please Print
Data
=1—
Job Location (� A. tX(-t( 2
Home Owner Address U- t,Q -P--
Home Owner Telephone - 2 '
Present Mailing Address L . • CC-
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 ,
Person(s) who owns a parcel of land on which helshe 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 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 fort acceptable to the Building
Official, that he/she be responsible for all such worst 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 "homeownee'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 7d re uirement#�
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code
A
CITY OF SALEM
;j PUBLIC PROPRERTY
DEPARTN/IENT
Construction Debris Disposal Affidavit
(requited 1br all demolition and renovation wuik)
In accurdancc (�itll the sixth edition of the State Building Code, 780 CNlR section I 1 1.5
Dcbris, and the provisions of v1GL c 40, S 54;
Building Permit H is issued with the condition that the dcbris resulting from
this work shall he disposed of in a pruperly licensed waste disposal I'acility as defined by MGL c
II1. S 150A.
The dcbris will be h:msportcd by:
(name ut hauler)
The debris will be disposed of in
(name of Iaalrty)
I:IaJres. of Iurllily) D
IA L
aula(we of p:nnn .y+pllcant
/G
J�Ir ,