32 GALLOWS HILL RD - BUILDING INSPECTION (2) ifs
t1 —� — -- --- The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 730 C'MR _ tiALC'\I
Building Permit Application To Construct, Repair, Reno ,to Or Denwl' a
Oiie-or Tivo-Fon ilr Dnvellin.K
` This Section For Official ,e ill
Building Permit Number: Date Ap lied:
Building 011icial(Print Nuinc)tt ig Dale
SECTION I:SITE INFORMATION
I.1 Pro arty drgs 1.2 Assessors blap& Parcel Numbers
��- /o•
I.la Is this an accepted street?yes_ no Map Number Parcel Nun,tnr
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District I'rupuzcd(is,; Lul Area(sq It) Frontage(11)
1.5 Building Setbacks(it)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required I'mviJeJ
1.6 Water Supply:(M.G.I.c.40,§Sa) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Privute❑ Zone: _ Outside Flood Zone?
Check if es❑ Municipal❑ )n site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Own rr o ecord: /
Name 1 Pnnt) City.State.LIP
No.and Street le ep� Entail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s)-❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ .Specify:
Brief es ription of Proposed Work': Oyu t „
/ c
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: -
(Labor and Nlalerials) I Ofllcial Use Only
I. Building S / 60O I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ? 0 O ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier _ _ ,x
i. I lurching S 00 2. Other Fees: S — -------
4. Mechanical tlll':\CI S List:
5. .\IccllarliLa1 (Fire
Su„re,sion) S - 'road :\llFees: S_ -__ - -- ---- -----...-- -
`( v. Total Project Cost: S J fie 0, Ell Check No. ___('hcck Amount: _ --_-- C,uh :\nmunt:
❑Paid in Full Cl Outstanding Bahmce Due: _
t
SECTION 5: CONSTRUCf10N SERVICES
5.1 Construction Supervisor License(C'SL)
License Numher Pgtiration Date
Name of CAl. I lulder
Lixt GSi.T%pe lice helots 1
__ --_—_.--- ----------- '1't Pe Description
No. and Street ----- It 14tresiricted IBuildin n up to 35.000 cu. It.)
R Restricted I r2 Family Dtwllin g
Cite/1"mil.State.LIP N1 Nfaionry
RC Rm lin Covering
_ WS Window and Sid"1
SF Solid Fuel Burning Appliances
I Insulation
I elc hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
IIIC Registration Number I p1rati011 Date
I IIC Company Nance or I IIC Registrant Name
No.and Street Email address
City/Town.State,ZIP Mc phone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 4 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 .......... E3 No........... ❑
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 Name(Electronic Signature) Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below,1 hereby attest under the pains and penalties of perjury that all of the information
contained in this app catiot is true and accurate to the best of my knowledge and understanding.
P
I't..t Ott ncr's or:\uth riled agent's N;unu Il.lwuunlc llgnafore) Date
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 t have access to the arbitration
program or guaranty t'und under M.G.L. c. 142A.Other important information on the HIC Program can be bound at
tttttt nl.r„ •.•Ot 1 Information on the Construction Supervisor License can be found at %\Nk,.inai.
2 When substantial work is planned, proe ide the information below:
Total fluor area(sq. ft.) _ (including garage. finished basement attics,decks or porch)
Gross living area(sq. ft.) _ Habitable room count -
\umberoffireplaces __ Number ofbcdroonts
Nuntherofbathroollts \'umberofhalfhallls ._ _ _... ._
I)pe of heating sy;tcnt Number Of decks- porches _
I'' Pe Ofcoolulg i\scent _ _ - I711closcJ
1, "tidal Project Square FoomgC" Ina\ he suhstinncd for"folal Project Cast"
CITY OF S. .04
PUBLIC PROPERTY
DEPARTMENT
' u.auu�wu�'aYL
wvoe i>ovw+�wfoMswaar•lnua�VnannwssrtsOl< 0
rtL 9'8-745.91" •jr.-A 93-716,960
HOMEOWNER LICLNSE EXE.I MON
Pkaw Ftrint
Date a2O
Job Location
Home Otenes Addteaa
Home Owner Telephone !27k- /2—
Present Mailing Address
The current exemption o!"Homeowner"was extended to include owner-occupied
dwellings of two Units or teas and to allow such homeowners to cagags an individual for
hire who.does not possess a lieasser provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Persons)who owns a parcel of Lnd on which he/she resides or intends to reside, on
which there is, or is intended to ber a one or two lkmily dweWag, attached or detached
structures accessory to such use and/or farm structures. A person who constructs more
than one home its a two year period shall not be considered a homeowner. Such
Homeowner'3W 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
PermiL
The undersigned "homeowner'assumes responsibility for compliance with the State
Building Code and other applicable bylaws and regulations.
The undersigned "homeowner"certilles that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
Mill comply with said procedures and req ents.
HOMEOWNERS SiGNATT,
APPROVAL OF BUILDING NSPECTOR —
See other side for state code
C[ .-[�r of S.wEa[, �tiL�ss.lcxt;SETI"s
l'+ 9UtLDLNG OEP.gmwiT
120 W-ts"L% GTON STAE$rs Jim FLOOR
ZLL (978) 743-9593
KOWERLEY DRMOLL F#,x(978) 740.984d
MAYOR niOaus sT.PWj"
D,x=TOR OP PL SUC PnOPHRTV/8E:MDLYG CO\L�ItSSION ER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition orthe State Building Cade, 780 CMR section 111.5
Debris, and the provisions of MGL a 40, S 54;
Building Permit M is issued with the condition that the debris resulting from
INS work shall be disposed of in a pro
111, S 1 SOA. perly licensed waste disposal facility as defined by AIGL c
The debris will be transported by:
(name of hauler)
The debris wi It be disposed of in
_�a.O�t14 S(fl6 CylCertr .�
(name o-
S(.J�Sto f�
(iddresf orraciJay)
+ ynature ofpermit.ppliunt
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