3 GREENWAY RD - BUILDING INSPECTION * &— / I (0
The Commonwealth of Massachusetts ►NSPECTIONAL RVUS of
Board of Building Regulations and Standards SALEM
j/ Massachusetts State Building Code, 780 CNI'Z 14 W iei.hl,lur?011
a' !Y G
Building Permit Application To Construct, Repair, Renovate Or Demolis a
One-or Tivo-Family Divelling
This Section For Official Use Only
Building Permit Number: Date Applied'
Building of icial(Print N:une) Signature Date
SECTION I:SITE INFORMATION
1.1 Pro erty Address: 1.2 Assessors t�lnp& Parcel Numbers
''Prater
rrr�i.(/tty "d
I.la 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(11) y
1.5 Building Setbacks(ft) 1
Front Yurd Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§Sq) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑ p p
SECTION2: PROPERTY OWNERSHIP!'
2.1 Ownert of Record: ' le14 �'f�/� pJ J7d
3�i.san Goct IC
thnie(Print) / City,State,ZIP S K n ` /
3 (� 'tnc�r/w/ ✓Cl 76177/ l7£fl ��son. �NcCIO,ems>. ��
No.mid St Telephone Gnuit Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alterntion(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Work-: in r 411 ' JNS-K runt v
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials)
I. Building S ) GG I. Building Permit Fee:3 Indicate how fee is determined:
❑Standard City/ u%vn Application Fee
2. Electrical S ❑Total Project Costa(Item 6)x multiplier ��`' x "
3. Plumbing S 2. 01herFees: S
I.Nlech;micai (FIV;\C) S List: l(J
i. Mechanical (Fire S :rotal All Fees:S
Su ress,un)
• Check Na._Check rintount: Cash Anunutt:
ti. Tufal Project Cost: 3 61000 ❑Paid in Full 11 Outstanding Balance Due:_
w)j6jj_$ECTION5: CON5'I'IiUCTIONSERVICES
5.1 Cmtstructinn Supervisor Liiceenste!(CSL)
d� .0 A d- RAP 01H License Number ETpiralion Date
N;unc of CSL Holder List CSL'rype(see below)
"type Description
No.and Street
U Unrestricted(Buildings tip to 35,000 cu. It.)
R Restricted 1&2 Family Dwelling
City(ruwn,State,ZIP iS( 'Masonry
RC Roofing Covering
WS Window and Sidirat
SF Solid Fuel Burning Appli:mecs
I Insulation
'fcic hone Gnail address + D - Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number E.epirution Dane
HIC Company Name or HIC Registrant Nome
No.and Street Email address
f City/Town,State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G,L.c.ISL¢ 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 Is§uance of the building permit.
Signed Affidavit Attached? Yes..........❑ No...........❑
SECTION 7a.OWNER AUTHORIZATIONTO BE COMPLETED WHEN:'
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT'
I,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 N:ane(Electronic Signature) Dale
SECTION 711b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,) hereby attest under the pains and (ties of perjury that all of the information
contained in this application is true and ac u to to dialtest my knowledge and understanding.
�t.SM C�
Print Owner's or Authorized Aga t%s ;one(Elegy onic'Signature) Date
NOTES:
1. An Owner wh"15tains 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 Lint 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
www.mass. v� y!iA Information on the Construction Supervisor License can be found at% w.ma,ssov!dtjji
�. 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 `lumber of half/baths
Type of heating system Number of decks/porches
'Type of cooling system Unclosed Open_
i. "Fwal Project Square Footage"may be.substituted r)r-fold Project Cost"
L
"i
r
°= QTY OF SALEM, MASSACQ IUSETTS
BUILDING DEPARTMENT
120 WASHNGTON STREET,31D FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KIMBERLEY DRISCOLL,
MAYOR TY-IOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT: L/
Date ` f yy�
Job Location J 6-1Y*tjA1, J/ / Set/,-M gl/ 0&70
Home Owner Address l�
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
�h• vZ'
CITY CIF S�UENf, tiL-1SSACHUSETTS
-lt tt, BUILONGDEPAR-nZNT
120 CV.ISHLYGTON STREET, 1 a FLOOR
�4
TEL (978) 745--9595
FAX(978) 740.9843
KIJiHERI.EY DtL(SCOLL
itiLma Tuo.%vLs ST.Pte^ARS
DIRECTOR OF PUBLIC PROPERTY/BCILDLNG COX
L\I155IONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 C?VfR section t 11.5
Debris, and the provisions of NIQL c 40, S 54;
Building Permit k 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 tbfCL c
I1 1, S 150A.
The debris will be transported by:
(name of lmuler)
The debris will be disposed or in
(narne ofracdity)
—'�(address oftacility)
i
mature of permit appIicam