19 GREENLAWN AVE - BUILDING INSPECTION v The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards Wilbraham
Massachusetts State Building Code, 780 CMR, 7"edition Building Dept
�\ Building Permit Application To Construct, Repair, Renovate Or Demolish a 413-596-2800
One- o-Family Dwelling
Ext 118
This cti n For Official Use Only _
Building Permit Number: Date Applied: Im 2 o g
Signature: E
Building missioner/In Build s Date
ON 1:SITE INFORMATION
Ll Property Address: �,/ q 1.2 Assessors Map& Parcel Numbers
l 62�O
19 �Ct l0.Wn w SaJGm, ^
Ma Number Parcel Number
l.la Is this an accepted street?yes ✓ no p
1.3 Zonin Information: 1.4 Property Dimensions:
Zoning District Proposed Use
Lot Area(sq ft) Frontage(ft) a
1.5 Building Setbacks(ft)
Front Yard - Side Yards Rear Yard
9
Re uired Provided Required Provided
Required Provided
1.6 Water Supply:(M.O.L c.40,9541 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O/On site disposal system ❑
Public� Private❑ Check if yes❑
SECTION 2: PROPERTY OWNERSHIP[ 1
Z.1 Owner'of Recornd: r 19 �p�„��,,,�r A e Sa(e,,,.., A,4
/�er�ol ♦�nHdTr�Name(P Address for Service: '
rint;)
G�Y'�✓ 9�8- 7Y'S YB"�
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Constmcnon ❑ Existing Building Owner-Occupied Repairs(s) ❑ Alteration(s) i Addition fS
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work':
�..skaIt �elle4
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building S y t/00. c77 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) S List: G
5. Mechanical (Fire $ Total All Fees: $
Su ression
(, Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ -/I y00,00 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date r'
Name of CSL-Holder List CSL Type(see below)
Address Type Description
U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature 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
1, "x d"/ 4„„L/_/, , as Owner of the subject property hereby
authorize I14y5?/ - to act on my behalf,in all matters
relative to work authorized by this building permit application.
i
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I, M,L`tao/ ,k ,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 -
jo/2�/mod'
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of e.'ur
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 M.G.L. c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 IO.R6 and I IO.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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 S'UEM
PUBLIC PROPERTY
DEPARTMENT
,u,maa AY•••o••,• 9 SAL6J4%••ss wnsEM 0'9'0
W�
1'�ww4Ut+L_'oN 1 77 S,9S9SS• FA)L 9711-740.964
H0MI E0WNER LICENSE EXE.rWrION
Pies"Print
Date 10ijOg
Z
dl ee� �Q Ave S0. seµ,. AAA
Job Location q ree I u < le�
ddre
Home Owner Ass $ y - 86 g
Home OwnerTe ePhone ct Gre „I o S� U y1✓l
Present Mailtna Address
The current exemption of"Homeowners"was extended to include ownow such homeowners to engageeruPied
for
dwellings of two Units or less and to Provided that the owner acts as supervisor
ess .
hire who.does not poss a license,Pro
DEFINITION OF HOMEOWNER
to residn' on
Persons) who owns a parcel of land on which he/she resides dwelling. or detached.
which there is, or is intended to be, a one or two family dwpa n who constructs more
structures accessory to such use and/or farm structures. A peso
than one home in a two Year period shall not be considered a homeowner.
to Building
homeowner"shall submit to the Building Official, on a form acceP
ible for all such work performed under the Building
Official, that he/she be respons
Permit.
The undersigned "homeowner" assumes responsibility for compliance with the State
Building Code and other applicable brlaws and regulations.
The undersigned "homeownd'certifies at he/she us derand ds trnrnu and City of Sthatalem
dshe
Building Departmrnt minimum inspec P
will comply with said procedures and requirements.
HOMEOWNERS HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING D;SPECTOR
See other side for state code
CITY OF SALEM
PUBLIC PRoPRERTY
DEPAR"I'MENT
'I'8.'7 q-s V_ '�CL
('onstruction Debris Disposal Affidavit
(rcyuired lire all demoIitiotI and rcnov ill iun work)
In accordance ill, the sixth edition of the State Building Code, 750 C NIR section 1 1 1.5
Debris, itnd the provisiutis of 1vlGL c 40, S 54;
Building Permit it is issued with the condition that the debris resulting from
this work shall he disposed of ill properly licensed waste disposal Iacility as defined by MGL c
Il1. S 150A.
The dchris "'ill be transported by:
I nantc of hutkr)
I he debris will be disposed of in
(name ul lac, av
a cnatwC of p.Wort .gtphcanl
/jo
Mali