49 GALLOWS HILL RD - BUILDING INSPECTION ( U The Commonwealth of Massachusetts Town of
L Board of Building Regulations and Standards
,Ix� Massachusetts State Building Cafe. 780 ChIR. 1'"edition- Budding Dept
Building Permit Application To Construct. Repair. Reno a Or Demolish a
One.or At o-Furrrrly Duelling
This a ion For VIcial se Onl
Building Permit Num rr t pplied:ly
Signature: I I )o/J cvo�
Building Conumsssoncr/ nspector of Bu) I Date
SECTION I SITE INFORMATION
1.1 Pro ny Addres • 1.2 Assesson Map R Parcel Numbers
c� t�5 lei\
✓no Map Number Parcel Number
I.1 a Is this an xc ted street'yes
I Zoning Information: 1.4 Property Dimensions:
2ontng District Proposed Vat Lot Area(sq n) Frontage In)
1.5 Building Setbacks(n)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.ed,say 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Public O Private O Check ifycsp
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Roe rd
Name e(PrinQ Address for Service:
l&rt-) q
Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(cheek aR that apply)
New Construction O Existing Building O Owner-Occupied O Repain(s) O Alteration(a) Addition O
Demolition O Accessory Bldg. O 1 Number of Units_ I Other O Speedy:
Brief Description of Proposed Work': i
(L , r i ivi7// c t..Wc� /.x1tS / -ec✓ l�/-K Ci9"b'�c
/;o✓n te4 fvo5
t
SECTION 1:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: OAlclal Use Only
Item it abor and Materials
1. Budding f /5' �.G•• 1. Building Permit Fee: f Indicate how fee is determined:
O Standard CiryiTown Application Fee
1 Electrical f t3 O Total Project Cost'(Item 6)x multiplier x
) Plumbing f OD 1. Other Fees: 11
A. Mechanical (HVAC) f Lisr.
t Mechanical (Fire S Total All Fees: S
Su ression
Check No. _Check Amount: Cash Amount:
d Total Protect Cost SYr�� I t7 p Paid ,n Full ❑Ouuundtng Balance Due-
T '
SECTION !: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) (�97,2 7 /3 2L /u
1'2yMee OA—i, Licensevumbvr E.puauonDate
N.yae ot('SL Hylder actsLnr('SL Type(at below)
i Description
nresmcted(up to 13,000 Cu. Ft.
2 ` 1 R I Restricted IA2 Family Dwelling
nat9%Td7�/ / W 1 Masonry only
RC Residential Roofing Covering
Telephone W S Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D I Residential Demofmon
5.2httered Home Improvement Contractor(HIC) , a�Cr g Z
oY" ' 17 f/t,=
HIC Company Name or HIC Regt Irani Name Regtstranonn Number
A�-7_—� �f� C171,P) �/�/�-it'; Expiration Due
Signarme Telephone \
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.1_c. 152.1 26C(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 f the building permit.
Signed Affidavit Attached? Yes.......... cv, No........... O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property hereby
authorize to act on my behalf,in all matter
relative to work authorized by this building permit application.
Si arum of Owner Dare
SECTION 7b:OWNER"OR AUTHORIZED AGENT DECLARATION
i1, 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
t Signed under the pains and penalties of
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 ya have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Constni ion Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 I0.R6 and 110.R5, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage. finished basemenNanics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
.Number of fireplaces Number of bedrooms
Number of bathrooms Number of halfbaths
Type of heating system Number of decks/porches
Ts pe of cooling systern Enclosed . Open
1 "Total Project Square Footage"may he .uh,limed for 'Total Project Cost"
-� CITY OF S.�.E.`[, AN xSSACHUSEM
' B1 II.DNG DEPARTMENT
120 WASHINGTON STREET, 3m FLOOR
TEL (978) 74S.959S
FAX(978) 740-984
KI*®FRt FY DRISCO[1
Twomu ST.PmRRt
HAY DR
DIRECTOR OF PUBLIC PROPERTY/lICIIDNG COMMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anttlicant Information Please Print Letzblr
Valna lBusidwv.Or4atstratiorolnthvtdu:J): � /P - h l/mot/_ �re�..e-tuX � �f+Zr�L�-y �[��.
Address- 5;7 12GSS —
City/Statdzip: 4�_ Phorte N:
,ore you to employer?Cheek the appropriate box: Type of project(required):
1.[9-11 am a employer with 4. Q 1 am a general contractor and 1
employees(full and/or pan-time)." have hired the subcontractors 6. ❑Now construction
2.0 1 am a sole proprietor or partner- listed on the attached sheet : 7. ❑ Remodeling
chip and have no cmployca Then subcontrecters have 8. Q Demolition
working for me in any expaciry. workers'comp.inalusnce. 9. Q Building addition
(No workers'comp. insurance S. Q We are a corporation and its l0.❑ Electrical repairs or additions
required.] otTlcers have exercised their
3.Q 1 am a homeowner doing all work right of exemption per MGL 11.Q Plumbing Pepsin or additions
myself.(Na workers'comp. C. 152.J 1(4),and we have no 12.0 Roof rpsin
insurance required.] t employe". two workers' 13.0 Other,
camp insurance requimd.j
•Any apptcant that checks 11011108 moat aW fill own Me feria below amw,icy their w,arkes'con msaih r policy intormallea,
'I hvrartw,rays who subsoil this aeldsre indicating they an doing all wait ad ohm hire aunitk contractors must mbmlr a new,atQdevit indicating fuel
['.,nnanars ghat clack this box mug attached an additwwl draw ahow,ing 00 tar Of*4 nab4oursfms and that, -Whoa'cwnp.policy interwtatiun.
/erne an employer that is pri v/d/nR workers'comptnsodar lnsaraearefer my exp/ayeas, ee/aw/i the pa/lay ee//a1 sits
information.
/?
insurance Company Name: '�'P• �� Q� . C�
Policy N or Self-int. Lie. /,M:/I 4:21?A,2 7 0 ?,V,' of<�G�gxpirrtion Data:
7 'y�f��24U
Job Site Address: C �lld"S /5�� -I'� City/StatNZip:
.%nsch s copy of the workers'compensation policy declaration page(showing the policy number and expiration date
Failure to secure coverage as required under Section 23A of MGL c. 132 can lead to the imposition of criminal penalties of a
fine up to S 1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day againsl the violator. Ile advi.%W(hats copy of this statement maybe forwarded to the OIYfce of
Invcaugatione ul'dha DIA for insurance coverage verification.
l do herby eery' r err i sun _Olelties of perjury that the information provided above is e unnd correct
`is;osRuec �l�'�"/ 1)atar rG/
O/Jlcia/aft a/r/r Da not tvrire in this area, to be Completed by city or town a//idol
City or fusrn: Prrmit/I.Iccnre e
1%suing.\ulhurity (circle tine):
I. 1ltrarJ of Ilrahh I. RuildlnU DepaTtmenr J. City/town Clerk J. Electrical inspector 3. Plumbing Impeeto►
6. Other
luotact Person: _ _ -_. _-_ Phone e'
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
w YCH ErT 15.\I I'\I. S1.\NS.N Ilt GI I1.:P,
I'm:WS-74;"9395 • r.\x:97e-740-9s*
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 It 1.5
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
l 11. S 150A.
The debris will be transported by:
/l tI116 eas--L
(name of hauler)
The debris will be disposed of in
(address of facility)
Signature of permit applicant
date
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