47 GALLOWS HILL RD - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
V / Massachusetts State Building Code, 730 CMR SALEM
Revised Mar 2011
DBuilding Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section,For Official Use Only
Building Permit Number, :: D " plt
Building Official(Print Na. Dale
SECTION 1: SITE INFORNIATION
Ll Property Address: 1.2 Assessors Map& Parcel Numbers
__q 5ua 6 ffiU 2A-
1.la Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public ❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes[]
SECTION 2: PROPERTYOWNERSII PL
2.1 OwnertlofRecord: �Gi
ha�d
�I�rru,t l
Naffic(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORIO'(check all that apply), .
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ I Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTEVIATED CONSTRUCTION COSTS
[tern Estimated Costs: 4,
Official Use Only-.
Labor and ivlaterials
1. Building S 1. Building PermitFee S Indicate how fee is determined:
❑ Standard.City/rown,Application Fee
2. Electrical S ❑'rota!Project CosC,(Item.6)x multiplier x
3. Plumbing S 2. Other Fees:'S
1. eal (llV:\l) S List:
i. cal (Fire S
ILn) Ibtal:\Il Fces:.S
Check No. Check Autount: Cash :\mount.
(. Total I'rnjeet Cult S y600•00 0 Paid in Dull ❑ Outstmuiin
,. " S Ilalattce Duo:
SEc'rION 5: CONSTRUCTION SERVICES
5.1 Coitstruclion Supervisor License (CSI.)
License Number Gepiration Dutc
Name ofCSL Bolder
List CSL Type(see below)
No. and Street Type Description
U Unrestricted DuilJin s u to 35,000 cu. tt.
R Restricted 15c2 F;unil Dwallin
City/Town,State, ZIP �I Masonr
RC Rootin Coverin
NS Window and Sidn..
SF Solid Fuel Burning Appliances
_ I Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC)
MC Registration Number Expiration Date
I IIC Company Name or IifC Registrnut Name
No.and Street Entail address
City/Town, State, ZIP 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 .......... O 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 Nam,:(Electronic Signature) Date
SECTION 7h: OWNEW OR AUTHORIZED AGENT DECLARATION
rByenteringy name below, I hereby attest under the pains and penalties of perjury that all of the information
is application is true and accurate to the best of my knowledge and understanding.
Autlwrin:d:\�nr's N:une(Electronic Signature) Date
NOTES:
I. :\n 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 find under M.G.L. c. l 12A. Other important information on the 111C Program can be found at
www.massoovioca Information on the Construction Supervisor License can be found at www.in:rs.,tu�dE
2. When substantial work is planned,provide, the information below:
Total floor area(sq. 11.) _ _(including garage, finislied basement/attics,decks or porch)
Gros; living area(sq. ft.) .— -- habitable room count--
Nuntber of titrplatcs _ Number of bedrooms _-- ------_--
Number of bathrooms _ Number of haltibaths
fvpo of heating.iystcnt - -_-_----- --_-- Number of decks/porches —_
f%pe of cooling sy;tcut __ Enclosed _--Open ---
1. I'wal I noject tiyu.trc Foo[I I_gc m:tv be iubaindcd fir 'I ,Ial I rojcct G)'t"
k:
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CITY OF SA LEM) .LLs&iujIJSETTS
BUILD4\G DEPAIUMEINT
120 WASHLNGTON STREET, 3w Roo rt
'ILL (978) 745-9595
lQ.%[3ERt Y DRISCOLL FAX(978) 740-9344
iILAYOR Tl los s ST.PIERAE
DIRECTOR OFPuaucPROPERTY/3L:lM 4GCONMISSIONER
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 1 l 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit 1t is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
JV4 ewe
nume�if hauler)
The debris will be disposed of in
C/oaC1 I�� s-/-f 7 e)5- m
(nantc of facility) -
(address of Facility---
sig,aturc o�Pllmltapp�licnt
,late
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t
CITY OF S.UY. N(
PUBLIC PROPERTY
DEPARTMENT
wroa t�a ol�owcrew!oast•lnua�wo�oa arrts Ott'0
nor.t'►7.17stt M.tt 97vas.9Ne
HOMEOWNER LICENSE EXE.I4"10M
Pies. hist - -
Due
Job Loeados /47`/ 1 �cl Sa /2Yt iY, /y/1� GY 9 0
HOM Owner Address V-? C�_a.11v�s /fi`/rI Yid �o /per mpg �
Horne Owner Telap boae� - o
PressoUsilingAddaeas y-1
The current exemption o["Homeownars"was extended to includo owner-occupied
dwellings of two Units at leas and to allow such homeowners to engage an individual for
hire who.don not possess a Ikasssr provided that the owner acts as supervisor.
DP 241MON OF HOMHOVIM
Pe sons) who owns a pateel o(WW on which hdshe resides or intends to reside.on
which there is, or is intended to bs6 a one or two tinily 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 O®cial,on a form acceptable to the Building
Official, that he/shs be responsible for all such wont 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 heishe understands the City of Salem
Building Department minimum impaction procedures and requirements and that hdshe
.vill comply with said procedures and re uirements.
HOMEOWNERS SIGNAmw
:APPROVAL OF BUILDING DiSPECTOR
See other side for state code