4 HILLSIDE AVE - BUILDING INSPECTION (3) �5
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code,780 CMR Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Seedon Fw 00 Use only,
Building Permit Number: Applied:
Bialding Official(PITIAName) Inue
SECTION I:SITE ITiFORMATIOiV
1.1 Pro ert);Address: 1.2 Assessors Map&Parcel Numbers
L �-1 t t_,_ t D l�_ W_N t_,r—
1.1 a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning Ilistnct Proposed Use Lot Area(sq it) Frontage(fl)
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: 1.8 Sewage Disposal System:
Public❑ Private❑
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2s PROPERTY OWNER51ItPi `.
2.1 Owner'of Record:hd 1
City,State,ZIP
Aik
Name(Printe It_�l O G � �_
No.and Strereett Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK;(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify---
Brief Des ' tionof Proposed Work=:
oK STYLv ��' no D
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
1.Building $ 1. Building Permit Fes:$ Indicate WOW fee is determined
❑Standard Cdy/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Five $ Total All Fees:$
Suppression
Cheek No. Check Amount: Cash Amotint:
6.Total Project Cost: $ 4 0 6p0 . ❑Paid in Full ❑Outstanding Balance Due: .
j�(Iht L� Tb A,O . IC5 [2�
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street 'MmV
U I Unrestricted 03uildings up to 35,000 cu.R
R I Restricted 1&2 Family Dwelling
City/Town,State,ZIP M 1111Maso
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town, State ZIP Tel hone
SECTION 6:"RKE:R.S'COMPENSAT14DN)DURANCE AFFWAVIT(ALG.I,.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:ONVMR AUTH RIZATJ10N 1.6 BE COAMLETEA WHEN
OWNER'S AGENT OR CONTRACTOR APPLE FOR ING PERMU
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. '
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
j'Print.Owner's or Authorized Agent's Name(Electronic Signature) Date
1. An Owner who obtains a building permit to do his/her own work,or an owner who hives 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 can be found at
w�vw.mass.eovIota Information on the Construction Supervisor License can be found at www.mass.wv/dos
2. 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 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 SALEM, MASSACHUSETTS
ye * BUILDING DEPARTMENT
120WASHINGTON STREET,3R FLOOR
\ non TEL. (978) 745-9595
FAX(978) 740-9846
KINMERLEY DRISCOLL
MAYOR THomAs STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
- HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date Li f•Cv
Job Location 1 c-'-!9 L D S V?�
Home Owner Address 11, -1 E_
Present Mailing Address A. I-k v'._
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
Y ��APPROVAL OF BUILDING INSPECTOR
CITY OFSALEK AL MSA( HLNEM
BtavmDErAFan•
120WA9MVXKS"Mffr,3mi DC§t
TkL(978)745.93%.
FAX(978)74498"
SIA�ERIEYDRLSODII,
MAYOR T)MucSTAMM
Dnmcnucc rrusuc /BtuDmamm mcma
Construction Debris Disposa/Afdavit
(required for all demolition and,renovation work)
in accordance with the sixth edition of the State Building Cie, 780 MR, Section 111.5 Debris,
and the provisions of MGL c8o, S 54; Building Permit 8 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 156A.
The debris will be transported by.
�a�u�tl� �nw�.K� �pw•
(name of hauler)
The debris will be disposed of in:
L,d to L4•u
(name of facility)
(address of facility)
Signatur of a plicant
Z
ate