21 GALLOWS HILL RD - BUILDING INSPECTION (2) lr
The Commonwealth of MassachuscltS
Board of Building Regulations and Standards Cl I'),OF
r Massachusetts State Building Code, 780 C•MR SALEM
'L,w Revived Ital._'ll/1
Building Permit Application To Construct, Repair, Renovate Or Demolish
One-or rwo-Fumilr Dn ellDre
This Section For Official Use 0111
Building Permit Number. Date App ied: 9
Building Olticial(Print Mane) Signature Date
SECTION I:SITE INFORMATION
1.1 P7ert Addregs�/ 2 r 1.1 Assessors blap& Parcel Numbers
I a�pOOS I 1 d
I.Ia Is this an acce ted street?yes ✓ no Mat,Number I'urcel Nunkr
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District I'mpused(Jse Lot Area(sq It) Frontage(It)
1.5 Building Setbacks(It)
Frum Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1.c.40,§Sa) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Munici al❑ On site disposal Check fifes❑ P system ❑
SECTION2: PROPERTY OWNERSHIP'
2. Ownerl of ecord:
wren MA 61 q7o
v N;unc PPJun)) �City.�Stale.ZIP
O. 6 ireet s �i�f RcI• C 1l0/ B CrAla-ftw (ore0kvf C4,1.0 4hv
No.;mJ Street
fetephune V Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building Owner-Occupied ❑ 1 Repairsis) Alterations) GrT Addition ❑
Demolition Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Briet'DescriptionofPropo ed Work A Sl [.a° oar,
oendiva, or
SECTION 4: ESTIMATED CONSTRUCTION COSTS
"r'
Estimated Costs:
Labor and.\lalerial5) Official Use Only
ng S gyp/coo I. Building Permit Fee: S Indicate how f'ee is determined:
ical S ❑Standard City/Town Application Fee
❑Total Project Cust'(Ilem 6)x multiplier _, x
ing S 2. Other Fees: S P -
ical ill\'.1('1 S Lisl: � .
nic:d tFire ----onI S rutal \II Fecs: SCheck No. ('heck Amuutn: Cash \mnt:
Project Cost: S 6 oo p --/ ❑ Paid in Full 13 Outstanding IIJIMCC Doc:
SECTION 5: CONS"1'Rl1C"PION SERVICES
5.1 ('onstruction Supervisor License(C'SI.)
License Number -"- �- Fgliratioo Date
N;une ofl'.SI. I lulder
I ist CSI. I'y pc bee helunl
------------------- ---------- 1'tpe Description
No. and tilfCCl '
U thtresricted(Ihtildin is ti to 35,000 cu. II.)
R Restricted 1.2 Family
Dwellin
l'itci loan.St;rtc.LIF bl Mason
RC' RtnHin Cuvcrin
._—._ N \4'indow and siding
SF .Solid Fuel Buming Appliances
_ I Insulation
1'ele hone Finail address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Registration Numher lapirotion Date
I IIC Company Name or I IIC Registrant Name
No.and Street Email address
City/Town,State,ZIP 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 .......... ❑ No...........Cl
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'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 Nave(Electronic Signature) Date
SECTION 7b:OWNEW 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 thi �application is true and accurate to the best of my knowledge and understanding.
1414111
Print Owner'i or Authorised Agent's Name(Flevirunie.Signat re) Date
NOTES:
I. An Owner who obtains a building permit to do his her own work,or an owner who hires an unregistered contractor
I nut registered in the Hume Improvement Contractor(HIC) Program).will no have access to the arbitration
program or guaranty fund under I.G.L.c. 142.4.Other important information on the HIC Program can be found at
wttw """ ' ' fta Information on the Construction Supervisor License can be found at tt>ttt was: �_�s dil,
2. \Phan substantial work is planned,provide the information below:
Total Iloor area I sq. R.) _ (including garage, finished basement'attics,decks or porch I
Gross living area Isq. it.) _ _ Habitable room count
Number of lircplaces,__ Number of bedrooms
Nmmher of bathrouns \'umber of half baths
I")Ile of heating sy;lem .. . _ `limber of decks, porches
I s Ile of coolllle s, Stem hllclosvd Open
I
1. "tonal Project Square Foolage"man he substituted for"Total Project Cost-
CITY OF S.UE.Ni
PUBLIC PROPERTY
DEPARTMENT
u.oWSY O.Ortl11
wrae 1301FUNNG oM 1nan•]uaK woAowQrn ett+!0
nL+-ar+sssss•F..a r.s.7+o.1sr
HOMEOWNER LICLNSB EXE.MMON
Pieces hint
No ►a *n
lobLoeadon 44i11 Pd-
Home Ownes Address 5^Mg 0(5, 770Z
Home Owner Telephone o
Pnaent Mailing Address !grn e us p oJ�
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 licenser provided that the owner acts as supervisor.
DERNMON OF HOMEOWNER
Passon(s) who owns a parcel of land on which hdsbe resides or intends to raider on
which than is, or is intended to bsr a one or two &Wly dwelling attached or detached
structures accessory to such use and/or farm strictures. A person who constructs more
than one hams in a two year period shall not be considered a homeowner. Such
"homeowner'sW submit to the Building Official,on a form acceptable to the Building
Official, that he/she be responsible for all such wort performed under the Building
Permit.
The undersigned"homeowner"assume 8 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 SIGNATLRE
APPROVAL OF BUILDING CiSPECTOR
See other side for state code
n
CITY OF S,UZN f, Akawf-iUSETI'S
9LLLDLNG 0EP.1R7\t&Nr
120 W.UHLNGTON ST>tr;BT, j A FtOOIt
T)!L, (978) 145-9595
KI1rBER19Y ORMOLL FAX(978) 740.9846
MAYOR THoust+ST.PtEnns
DIIIECtOROPAlE1L1CPROPEA Y/at:MDL%4GCOSLA(ISSIONER
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 11 I.S
Debris, and the provisions of MOL a 40, S 34;
11 Building permit p is issued with the condition that the dcbris resulting from
work shall be disposed a prop
of in erly
1
l 1, S I SOA. licensed waste disposal facility a, dcfincd by MOL c
The debris will be transported by;
(name arhaul40
The debris will be disposed Orin
(name o�c1lj�y)
(iddress or racilijy)
❑ynamra o(permrt,pphcant
�a�hl�ll
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