4 HILLSIDE AVE - BUILDING INSPECTION (2) The Commonwealth of Massachusetts arY OF
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR S
�) Revisedd Mar 2011
Application To Construct Repair, Renov Demolish a
Building PermitA P
gPP
One-or Two-Family Dwelling
This Sectiofi For Official U -0nly
Building Permit Number: Date Ap ted:
Building Official(Pnnt;Name) Signatures Date
SECTION 1: SIT INFO ON
1.1 P open Address: IV Ass ors Map& Parcel Numbers
1.1a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning In
1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
11.5 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: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yesI3 _
SECTION2:, PROPERTYOWNERSHIP''
2.1 Ownert of R orul
�c/�on lIQ,jIe1' e, r�dn MA l�rl97o
Name(Print) City,State,ZIP ' —��
Nl dfid f Nil
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF.PROPOSED WORKr'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Cl I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number afUnits Other ❑ Specify:
Brief Description of Proposed Work: nri-t-l'i'A C Gt //n
SECTION 4: ESTIMATED CONSTRUCTION COSTS,
Estimated Costs:
[rem Official Use Only..,
Labor and Materials
I. Building $ I Building Permit Fee-S rndicatehow fee is determined:
�. Electrical S ❑ Standard;City/"r6%vn,Application Fee
❑Total Ptoject Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
Fr,
echanical (lIVAQ S List:
Mechanical (Fire S
ression) 'Ibtal:\II Fees: s .
Check No. Check Amount: _Cash :\mount.
otal Project Cost: S C?5ai O0 l ❑ Paid in Fill ❑.Outstanding Ballace Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number E.piration Datc
Name of CSL I loftier
List CSL Type(see below)
No. and Street Type Description
U Unrestricted (Buildings up to J 5,000 cu. tt.
_ R Restricted1&2 Family Dwelling
City/Town,State, ZIP M blasonr
RC I Rooting Covering
WS Win(loVv it tliI
SF Solid Fuel Burning Appliances
I Insulation
'rcle hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration DI-1
IIC Company Name or FIIC Registrant Name
No.and Street Email address
City/Town,State,ZIP 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 PERNUT
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.
Print Owner's Name(Electronic Signature) Date
7SECTION 7h: OWNER' OR AUTHORIZED AGENT DECLARATION
enteringe below, I hereby attest under the pains and penalties of perjury that all of the information
lication is true and accu ate to the best of my knowledge and understanding.
rized:\;ent's Name(Electronic Signature) Date
NOTES:
I. :\n 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
PS
ro gran or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at
ww v ;a; „nA1 is
, Supervisor License can be found at n .m t.. ._(
(aww.n:,u<. uv.'ucu Information on the Construction p _�
2. When substantial work is planned,provide the information below:
Total floor area(sq. (t.) _ _(including garage, finished basement/attics, decks or porch)
dross living;trey(sq. It) —_ Habitable room count
Number of titepl:aces,_-- Number of bedrooms "-- -----_--
Number of bathrooms Vunber of haltibaths -- -- _
--------- --
Fvpe or heating systenn .-.. ---_ ----_-- Vumber of decks/porches
I!e of cooling sy;Icnt -.--- ------ Enclosed __Open --_ —.--
}- lot.d Pfoioct Square Fo,ta,e" may be sub,tihnrd t»r Project C,);[" --
CITY OF S.ULE.N(
PUBLIC PROPERTY
DEFART,. LENT
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HOMEOWNER LICLNSS EXE.HPTIOV
Pfsw lriat
Due Z//Z —
!ob Latatios z/ //i//r,4)0 �V r° �a Lpvri ✓n A r�197 U
HomeOwtasrAddras y rc, am Mo W2,70
Home Owar Telephone c/-7 9 L/ - 4 () � �
Preamt MWiag Addrar L/ !' V e 57L oar rnA dJY V 1
no currant exemption od"Homeowners"war extended to inclu"owner-oeeupied
dwsuinge of'two Units or teas and to allow such homeowners to engsgs an individual for
hire who does not poseeaa a ueenas,provided that the owner acts as supwWsw.
DEFINITION OF HOMHOWNF.Tt
Person(s) who owns a pateal of land on which hdshe raids or intends to reside,on
which then is, or is intended to be6 a oce or two fhm%ly dwellhsg, attached or detached
structures wceswry to such use m&Ot farm structures. A person who conAMWO more
than one horse in a two year period shall rsot be considered a homeowner. Such
"homeowner"shall submit to the Building Orflcial on a form acceptable to the Building
Official, that hdshe be responsible for all such wort performed under the Building
Permit
The undersigned "homeowner"assumes responsibility for complianee with the State
Building Code and other applicable bylaws and re8wadons
The undenigned "homeowner"certifies that hdshe undentands the City of Salem
Building Department minimum inspection procedures and requirements and chat hdshe
Will comply with said procedures and requirements
HOMEOWNERSSIGNATLM
APPROVAL OF 9UILDI.VG ViSPECTOR
See other side for state code