53 GALLOWS HILL RD - BUILDING INSPECTION (2) The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or fish a
One-or Two-Family Dwelling
r. This Section For Official Use Only
Building Permit Number - Date.Apphed s
t GLIlA4A�._ Signature
.. .Date,
uildmg Official(Pant Name) �, .
-.
SECTION l SITE INFORMA,:.ON '
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
53 Gqu ws frill em
�. 1.1a Is this an accepted street9 yes_ no
Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Propos L ot Area
ed Use (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.G.L c. 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yes[]
y SECTION 2:;(PROPERTY OWNERSHIP'
2.1 �Qwngri of Record: �� 0("('7
(l �vNna t oy Y �/
Name Print) C!* State ZIP
fr 2q !R_Y?I ` t-�G1.eSW0 1T l Co cc s - rP_t
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'-(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Un' Other ❑ Specify:
Brief Description of Proposed Work': o L
SECTION 4: ESTINIATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
1. Building $ tf, o0v- oo I Building Permit Fee $ Indicate how fee is determined:,
❑ Standard City/Town App ipation Fee
2. Electrical $ 11 000. w ❑Total Eiodect Cost'(Item 6)x multiplier
3. Plumbing $ 2 Othe>.Fees: $
4. Mechanical (HVAC) $ List
5. Mechanical (Fire $ Total All Fees: $
Suppression) -
Check NO Check Amount Cash Amount
❑ Outstanding Balance Due:
6. Total Project Cost: $ L/ 0 Paid in.Full .
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No. and Su-eet Type_ Description
U Unrestricted Buildin s u to-iI00 cu. ft.
R Restricted LU Famil Dwelling
City/Town, State,ZfP NI Nlasonr
RC Roofin Coverin
WS Window and Sidin
SF Solid Fuel Burning Appliances
I Insulation
Tele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or I-f[C Registrant Name
No. and Street
Email 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 .......... ❑ 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: 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 this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Siguanue) Date
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 not have access to the arbitration
program or guaranty fund under NLG.L. c. 142A. Other important information on the HIC Program can be found at
www.mass.,ov/oca Information on the Construction Supervisor License can be found at www.tnass eoI�dos
?. When substantial work is planned, provide the information below:
Total floor 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
Type of cooling system Enclosed Open
3. "Total Project Square Footage" may be substituted for"Total Project Cost"
CITY OF SM-04
PUBLIC PROPERTY
DEPARTMENT
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HOMEOWNER LICENSE EXE.MM04N
Plow "I /
lob Location S 3 G ( l 6 vs t I
Homo Owoar Addmas
Home Owner Telephone (fl V V I j
Present Mailing Addtteae 5-`3 [ �✓
The eunnsret a:empdan of"Homeowners"was extended to include ownsr-0ceupied
dwelfinge ottwe Unite or fear and to allover such homeowners to engage m individual for
hire who dos not poasew a license provided that the owner acts as supervisor.
DEFINITION OF HOAaOWNIHfi
Person(s) who own@ a pared of Lnd on which hdshe resider or intends to resider on
which there is, or is intended to be a on or two Atmily dwelling attached or detached
structtim accessory to such us@ and/or farm otruetura. A paws who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner'shall submit to the Building OQfcia4 on a form acceptable to the Building
Official, that he✓sh@ be responsible for all such work performed under th@ Building
Per;rniL
The undersigned "homeowner'assumes responsibility for compliance with the States
Building Coda and other applicable bylaws and regulations
The undersigned "homeowner'certifta that hehh@ understands the City of Salem
Building Department minimum inspection pracedur an uimments and that he/she
Will comply with said procedures and requirements
HOMEOWNERS SIGNATL`RB
APPROVAL OF SUILONG LNiSPECT'OR
See other side far state coda
a
CITY OF S.�LE'm, � NSSACHUSETrS
BL'ILDNG DEPART'%MINT
u 130 WASHINGTON STREET, 3' FLOOR
TEL. (978) 745-9595
FAA.(978) 740-9846
KIA{gFRt FY DRISCOLL
i14.�YOR T�toat�s ST.PtERRs
DIRECTOR OF PUBLIC PROPERTY/BCILDNG CONLMISSIONER
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# 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:
(name of hauler)
The debris will be disposed of in
(name of Facility)
(address of facility)
signature of per 't a plicant
date
Icbi i.>d Ii ,W -
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