53 GALLOWS HILL RD - BUILDING INSPECTION 1 The Commonwealth of Massachusetts
I� Board of Building Regulations and Standards CITY O]1/
Massachusetts State Building Code,780 CbIR SALEM
Building Permit Application To Construct,Repair, Renovate Or Demolish a Revised Mar
One-or Two-Family Divelling
This SacftonForOfficial Use 0
Building Permit Number: Date Applied.
Building Offleial(Print Name) signally Date
SECTION 1:SITE INFORLNEA
L1 Proper�t3'Address: 1.2 AssessorsWfap& Parcel Numbers -
��
I.Ia Is this an accepted street?yes V 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 Setbacla(fQ
Front Yard Side Yards Rear Yard
Required Provided Raquired 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 ifyes
SECTIONZ PROPERTI6'OWNERSHIPL '` "
2.1 OO pert of Record
S 2 oy t_.�c S_� r,l 6 i 7 C7
1 ham. a - 17
Name(Print) City,State, P -@saw kl
4,rl 2'
No.and Street .. Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSEB.WORK"'(check all that apply):
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) O Alteration(s) ❑ Addition ❑
Dzmolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work": De t o c, k t
SECTION 4: ESTIrNLATED CONSTRUCTION COSTS
Item
Estimated Costs:
Official Use Only-:
Labor and Materials
1. Building Sjoo. Do L,Building Permit Fee:S Indicate have fee is determined:
?. Electrical
❑Standaid.City/Town,Application Fey.
$ . ,.
cl Total Pitiject Cost".(Item 6)x multiplier x
3. Plumbing S ?. Other Fees:'S
t. Mechanical (IIVAQ S List:
. Mechanical (Fira S
X Sup iressio o _ total:lll Fees:5_
Check No. _Check Atnuunt: _dish r\utount:.
Filial Pro Cu.;C S �io op. oo f 13 Paid in Full ❑Outstanding Ilillance I)ua:
J
SEC'rION 5: CONSTRUCTION SERVICES
5.I Construction Supervisor License(CSL)
LianstNumbcr Expiration Date
Name of CSL I folder List CSL Type(ice below)
type Description
No. and Street U Unrestricted Duildin s on to 35.000 cu. tt.
R Restricted 1&2 Family Dwellin
Nlason
Citylrown,State,ZIP M Rucrin
RC aotin Coverin
INS Window andSidin+
SF Solid Fuel nursing Appliances
I Insulation
felt hone
Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC)
MC Registration Number Expiration Date
E IIC Company Name or IIIC Registrant Name
Email address
No.and Street
CityiTown.State ZIP role hone
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 .......... 13 No...........❑
SECTION 7a:OWNER AUTHORIZATION TO 11E CObIPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERM[T
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.
Date
Print Owner's Name(Electronic Signature)
SECTION 7b: OWNER' 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 t t e st of my knowledge and understanding. /— 13
Date
PrintOwncr'sorAutlwrired:\gant'sNante(Gcc«onto ignntun)
NOTES:
net who obtains a building permit to do hisiher own work,or an owner who hires an unregistered contractor
(nut r gistered in the Home Improvement Contractor(HIC) Program),will not have:recess to the arbitration
progrun or guaranty fiord under NI.G.L, c. 142A. Other important information on the 11 at Program can be found at
www mas:.euv%ura Information on the Construction Supervisor license can be found at tvww,uta;s.• uy,�'dp_;
2. When substantial work is phmned,provide the information below:
total floor area(sy. It.) ---__ _(including garage, finished basemenVattia,decks or porch}
tine; f l
living;trca(sq. ft.l _— Number
room count
er of
—
Nuniltefbedrnoms ---
Mimber of Number of liAtbaths
1\peofhc:aing ;y;tent
t)pen
1'tpeole )nlim�" ;yacnt
t. I'„oil I'ngrrt sgmlla Foot MAY he ;nbstitut.,l t:+r I', t.il Pliiiil
CITY OF S. -FNf
PUBLIC PROPERTY
DEFARn. fEN'T
VfOWfi/Nr•.y�
wrae
t x v�s•ar,,c,,,!►+aaa• suu4,Hww�+assrst ots'0
tta.•-anssstN •r�s,r.rzne•�w
HOMEOWNER LICENSE E.XE34pTI0►V
Please "t
Due � ral -13
lob Ioeados
Home Owmm Address G c.kws y,
Home Owner Telepbooe
Preaaot Mailing Address C_- o..>s
Tie curreat exemption of lifomsownsa a wee eat WW to include owner oeeupied
dweUings of mo Units at fen sad to allow such homenwaen to cnpp an individual f
hire who does not poem a Ueasq provided that the owner acts n,ruperviaor or
DEFINITION OF HOMEOWNER
Person(s) who owns a pareal otlaod on which he/she resides or fatends to reWdo6 on
which then isti or Is intended to bo,a am or two lhmily dwelling, attached or detached
swxturm accessory to.such use and/or WIN sWicturem A person who coaatructs more
than one home in a two year period shall not be cotWdered a homeowner. Such
"homeowner"shall submit to the Building 0i feiab on a foam acceptable to the Building
Official, that he/she be responsible for all such work performed under the Building
Permit
The undersigmW "homeowner"assumes responsibility for compliance with the State
Building Cods and other applicable bylaws and ragulatlons
The undersigned "homeowner"ceroAes that helshe undentands the City of Salem
Building Oepaatment mitsimwn inspection procedures and requirements and that he/she
.sill comply with said procedures and requirements
HOMED WNERS SIG.NA TLRB
IPPROVAL OF BUILDIYG iNSPECTOR
See other side For state code
1
CITY OF S,6V-ENf, jAks wHUSETTS
,1_ ',�)� QI:ILDLYC DERIRT1lENT
120 TUHNGTON YT'RE&T, Yd FLOOR
,u g I c.L. (978) 745-9595
KIMOULEY DRISCOLL F.%-%(978) 740.9345
N LkYOlt 1110.N4'U ST.nEAM
Dt:tECCOa OF Pt:OUC PROPERTY/at:ILDCI(3 CONWISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renuvation work)
In accordance with the sixth edition of the State Building Code, 730 C&fR section 111.5
Dcbris, and the provisions of tbIGL a 40, S i4;
is work shall be Permit hih 11 w is issued with the condition that the debris resulting from
t 1, S I SOA.
this disposed of in a properly licensed waste disposal racility as defined by N1GL c
The debris will be trnnsportcd by:
(njnta ut•haulcr)
'Clte debris %vill be disposed of in
-- (nanw of t'acility)
T,Ta'—dI of rii�ilit/)
s igneuuo of permit app '• nr
C;1 )
5