55 GALLOWS HILL RD - BUILDING INSPECTION (2) -7610
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALliW
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Massachusetts State Building Code, 780 CMR Revired.VgWl
Building Permit Application To Construct, Repair, Renovate Or Demolish a z
One-or Two-Family Dwelling m
This Section For Official Use Only
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Building Permit Number. Date. plied
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Building Olitc,al(Print Name). Signature - Ilat
SECTION 1:SITE INFORrNIATION` H
1.1 roperty Address: 1.2 Assessors Map&Parcel Numbers
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1.1 a Is this an accepted street?yes ao Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
_ Zoning District Proposed Use Lot Area(sq tl) Frontage(It)
1.5 Building Setbacks(it)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone? Municipal ❑ On site disposal system O
Public❑ Private❑ — Check if es❑ p pO y
SECTION2: PROPERTY OWNERSHIP!
2.1 wnerl ^ Record: M i'J'_J U
J�4S I>0'1 Lt:- AUE^,,
1��rne(Print City,State,ZIP
/; �Jr �'Jy S t ( � K 7 Cd'7L$3L-" -(
Nu.nnJ Slrect Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition O Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': M � `A 7 S c,I I e f-7 c
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials -
I. Building $ 1. Building Permit Fee:$ Indicate how fee is Determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(item 6)x multiplier x
3. Plumbing $ 1%9ther Fees: $
d. Mcchanical (HVAC) S - List:
5. Mechanical (Fire STotal All Fees:S
Su ression)
Check No. Check Amount: Cash Amount:
G. 'fotal Project Cost: S 3 OJC; OU ❑p;tiJ in Full ❑Outstanding Balance Due:
SEAT tl��
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SECTION 5: CONSTRUCTION SERVICES
5.1 Constructiui Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder List CSL Type(see below)
Type Description
No. and Street
U Unrestricted(Buildings Lip to 35,000 cu. 11.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D . Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
I IIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town, State ZIP Tel e hone
SECTION 6:WORKERS'CONIPENSATION 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 Is4uance of the building permit.
Signed Affidavit Attached? Yes ..........❑ No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE CONIPLETED.}VHEN:'
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Narne(Electronic Signature) Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I It st under the pains and penalties of perjury that all of the information
contained in this application is trued a orate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's nsc(EI ctronic Signaure) Date'
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or art owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(1-11C) Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. I42A. Other important information on the HIC Program can be found at
svww mass eov'oce Information on the Construction Supervisor License can be found at www.muss.eov' .
2. When substantial work is planned, provide the information below:
Total tloor area(sq. ft.) (including garage, finished basementlattics,decks or porch)
Gross living area(sq. It.) Habitable room court
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
of he sting 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 SALEM, MASSAC IUSETTS
BUILDING DEPARTMENT
120 WASHINGTONSTREET Yo FLOOR
TEL. (978) 745-9595
FAx(978) 740-9846
KIbIBERLEY DRIS LOLL
MAYOR THOMAs STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMNIISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date
Job Location
Home Owner Address Sq v—f
Present Mailing Address
The current exemption of"Homeowners" was extended to include owner-occupied dwellings of two
Units or less and to allow such homeowners to engage an individual for hire that does not possess a
license, provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or
is intended to be, a one- or two-family 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 Official, on a form acceptable
to the Building Official, that he/she be responsible for all such work 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 he/she understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR
CITY OF SALEM, MASSACHUSEM
BUILDING DEPARTMENT
i fix ' 120 WASHINGTON STREET,31D FLOOR
TEL. (978)745-9595
KIMBERLEYDRISCOLL FAX(978)740-9846
MAYOR THomAS STJIERRE
DIRECTOR OF PUBLICPROPERTY/BUILDING CONMUSSIONER
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 111.5 Debris,
and the provisions of MGL c40, 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 deposit 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)
(L
Signature of a licant
) 3
Date