17 GREENWAY AVE - BUILDING INSPECTION 1� The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
m
V ti Massachusetts State Building Code, 780 CMR, 7 edition OFSALEM
Revised Jawury
Building Permit Application To Construct, Repair, Renov a Or Demolish a 1. 2008
One-or Two-Family Dwelling
This Sectioryf4r Official Use nl
Building Permit Number: 4 Qa.*Appl' d:'/
Signature: -70,0 7/���-0
Building Commissioner/Inspectorof Butidi Date
SECTIOlf. SITE INFORMATION
1.1 Property A ress: 1.2 Assessors Map& Parcel Numbers
�/
ucll
1.1 a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq it) Frontage(it)
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: I.S Sewage Disposal System:
Public 0l1 Private❑ Zone: _ Outside Flood Zone?Check ifyes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record �—
Tn A rO tQT I tU '7 DO-r-J
ame(Print) Address for Service: `
97F 77'-/- 4/ 7 -/
Signature 'Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) K I Alteration(s) ❑ I Addition ❑
Demolition KJ_Accessory Bldg.❑ 1 Number of Units_ I Other ❑ Specify:
Brief D riptio f Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
1. Building $ I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (11VAC) S List: r h
5. Mechanical (Fire S
Suppression) Total All Fees: S
6.Total Project Cost: S 7 d o Check No._Check Amount: Cash Amount:_
❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction S ervisor(CSL) �7100_? 7— `o— ( I
License Number Expiration Date
Name of CSL-I[older List CSL Type(see below)
0 f.PC Description
Addre U [Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signature y/! M Mason Only
o_7S' 97S 73 .7 / RC Residential Rook-in Coverinix
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. 152.1 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 ..........0 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 matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 71[k:O ERt OR AUTHORIZED AGENT DECLARATION
-,as Owner or Authorized Agent hereby declare
that the statements and informatj n on the foregoing ap tcalion are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of 'u
NOTES:
I. 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 no have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 C M R Regulations 110.R6 and 110.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"
<� Board of Building Regulatio sand St"14 snd rda
HOME IMPROVEMENT CONTRACTOR
Registration; 123682
Expiration: 3I24I2011 Tr# 282104
Types; Individual
DONALD KELLOWAY //_ `� 5
Donald Kelloway
128 HAMSHIRE RD.
METHUEN,MA 018" Administrator
CITY OF SM.&M, NWSACHUSEM
9LB.DING DEP.IaTIE iT
120 WAsNINGTON STuff, r FLOUR
TtrS,. (978) 745-9595
'a F.%x(978) 744980
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Workers' Compensation Insurance Allldavif: BuilderslContractorslElectr(c(anslPlumbers
a t licant Informs11011 Plessil
A Print
V21ne lduur Ortantrahl v,duall: i- )Ort1 4 �•7 0 c�j At
Address: 14 0 on LJ-rMl n"k 14 f e&—
city/state/ziP: IZA L-,--rw can•✓ V ,4- ICnl. y � 97s'� 7 3 7
Are you as employer'Ckeek the appropriate boa: Type orproject(required):
1.❑ I am a employer with 4. Q 1 wa s Srocral coa0setor and I 6. Q Now construction
unploycee(full and/er pan-time)•e have hired the arbcarmacon
2.01 am a sole proprietor or pmuter- listed an the attached she: y ❑Remodeling
*hip and have no employee Them sub-contractors have 21. Q Demolition
working for me in any capacity. workers'Comp,instnaooe. 9. Q Building addition
[No workers'comp insurance S. Q We are a corporation and is
requital.]
offMn haw exercised their 10.0 Electrical repairs or additions
).Q 1 am a homeowner doing all work right of eamnption per MOL I I.Q Plumbing repairs or additions
myself.[No workers'comp. C- 15Z 110).and we have no 12.0 Roof repairs
insurance required.)► %:mployea.[No workers' I S.Q Other
comp.insurancerequired.J
.
Any apruraw thd drones beti tl onus alas nor uw tM rug brow tboaiq tMk aaaee'ranautsdobb Pdky'ieatrbtbsbltit►
t 1l.onr.. an,who ations ibis anldva indladq ta mk W dim him we Join/all w hie wrsir Now
t,A dj a row aMdr it 4,di aiq eats
:l'.anamntMr climb ibis bon rmat anhadan sididwal Awl,1--no th"nuns ottlivala•aatnane"W,h*wot- .Cool•Piky'inrmmWs
f anti as tmPleytr that 10Prerldn;nvrAtrs'romPraasdrn hanrsaxrfa►my existaytasl Bohm IS Ike pd&y aadm Jim
information.
Insurance Company Name:
Palicy M or Self•ins.Lie.ll: Eapiralios Data:
Job Sire Addrem City/SlawZip:
Attack a copy of the workers'compensation policy d"Watin PAP(showing Ike policy number and aspiration data}
F;tiluro to sure coveralls as required under Section 23A of MGL a 152 can lead to ilia imposition of criminal penalties of■
fine up to S 1.500.00 and/or one-year imprisonment,ar wall as civil penalties is the form of a STOP WORK ORDER and a line
Of up to S230.00 a day uyainst the violator. lie adviuxl that a copy of this srati mu a maybe rurwarded to the o171ce of
Invc,ngariuns of ilia MA far insurance covaaga v.;nfwalioa
f Jar hereby certify�71jfzrja pains and Pena of perjury that$As infaratatlaa provided abovve/ee�is true and a arrrea
`"' t I)ylgtC Za�
?. ore a: l 7
O/�a•itl use rods Oo naI write is thi"aura,la M,arwp/t/d by airy or taw•/a/fii'iaL �
I
City or ruivn: YrrmiN.letnre e
luuing Aulhunty(circle une):
I. Ilsnrd ut Ilrallh 2. Ruilding Department 1. c;iytrowa Clerk 1. Electrical Inspector S. Plumbing Impactor
6. Other
i L.,Macl Prnan: _ _ Phone a•
�S CITY OF SALEM
i PUBLIC PROPRERTY
DEPARTMENT
X.W 01h1 ''KNi II
-A I_'Q� \il II\b;)>.N SCNLI'T •).\I I M.
1'F1:V11-145Aj95 •1'.\X:978•14499I6
Construction Debris Disposal Af idavit
(required fur 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 c 40, S 54;
Building Permit p - . _ 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 l 1. S 150A.
The debris
/will be transported by:
1 name of hauler)
The debris
will be disposed of in :
(name ut ui rty)
(oddrnss ul 1'ac1111Y)
%1palure o1 hermit a llicant
late
Ichn.,li i:K