5 HILLSIDE AVE - BUILDING INSPECTION (3) The Commonwealth of Massachusetts
aVIC
Buard of Building Regulationsand Standards CITY OF Massachusetts State Building Code, 730 CMR SALENI
Revised tNar 2011
Building Permit Application To Construct, Repair, Renovate Or De qila
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number:' `Date , pphed
Mgr .
Building Official(Print Name) Signature Date
SECTION 1: SITE'INFORNIATION
Ll Property Address: 1.2 Assessors Ntap& Parcel Numbers
1.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 ft) Frontage(ft)
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 Z:, PROPERTY OWNERSHIP4'
2� �QtwnertofRecor '
I�I.t c�ti:A.� A. :7 a e
Name(Prints City,State,ZIP
o —o fgel
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK"(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Cl I Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposecl,Wor Z: V
J
SECTION 4: ESTENIATED CONSTRUCTION COSTS-
Estimated Costs:
Item Official Use Only
Labor and N[atcrials
1. Building $ I Building Permit Fee S-_Indicate how fee is determined:
�. Electrical S ❑ Standard.City/towrrApplication Fee
❑Total'Project Costa(Itemb)x multiplier x
3. Plumbing 'S 2. Other Fees:'S
k Mechanical (HVAC) S List:
i. Mechanical (Fira S
Suppression) "Cotal:Vl Fees: S
Check No. __Check Amount: Cash Atnetalt:
�) I'utal Project Cost: 1
21✓�jt7 0 Paid in Pull ClOutstanding Balance Dua:
SECTION 5: CO;Ns,rRUC'HON SERVICES
5.1 Construction Supervisor License(CSL)
License Number -Expiration Date
Name oFCSL 1lul i r
List CSL Type(see below)
No. and Street T
ypeDescription
tricted Ruildin s u to 35.000 cu. ft.
.�' cted 13e2 F;unil Dwellin
Citylrown, State,ZIP r
n Cuvcrin�
/ w and Sidin,
Fuel Burning Appliances
tion
'1'ele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(IIIC)
_ HIC Registration Number Expiration Date
IIIC Company Name or IIIC Registrant Name
N 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 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.
Print Owner's Name(Electronic Signature) Date
SECTION 7h: OWNEW 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 it and orate to best y knowledge..and understanding.
Fr-int^ caller s or Authorized.A s Nome ctrunic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor
(nut registered in the Houtc Improvement Contractor(HIC) Program),will not have access to the arbitration
program or guaranty timd under M.G.L. c. 142A. Other important information on the IIIC Program can be found at
www.nlass.,,uv/oca Information on the Construction Supervisor License can be found at www.ntass.%_411L-q
2. When substantial work is planned, provide the information below:
Total floor area(sq. ff.) _ _(including garage, finished basemenUartics, decks or porch)
Gross living mea(sq. ft.) _ habitable room count
Number of fit eplaccs_ — Number of bedrooms
Number of bathrooms _ Number of half bailis _----
['ype of homing system - _- —_ — Number of,leeks/ porches .-----__—
Ilpeofcoolingsy;tcm_____--------___,__-- F.uClused-- (.)Pon_
} l of II Pl oj,eCt Squ Ire root 1 e" 11my he illhitinited tOr 'I,otll IllojcCt Coo t"
CITY OF S-U.E-N(
PUBLIC PROPERTY
DEPARTNIENT
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HOMEOWNER LICE.NSB EXE-MMON
P1ew Mat
Date 31 re L L3
Job Locados
Homeowner Address _a ^c;
H�owner Telephone
Ptt sr t Us'ilia 8 Address tz
Occupied
The cum
t exemption of" m Hoeowners"was extended to include owner
a cappindividual for
dwelling,of two Unite or lax and to that the owner acts as supervisor
hits who does not poatnas a BemK provided
DE,FQ MON OF HONMOWNE.>h
el Ou
Persoo(s) who owns a panel o[laod on which hatshe resides err Inds tohad re detached
which then is, or is intended to be, a one or two family dwelling, ZUW
structures accessory to such use and/or farm structures. A person who constructs more
than one home in a two year period shad not be considered a homeowner. Such
"homeowner'shall submit to the Building Official,on a form acceptable to the Building
Official, that helshs be responsible for all such wort performed under the Building
permit
The undersigned "hoolcownea"isaumes reaponsibiGty for compliance with the Scats
Building Code and other applicable by-laws and regulations.
no undersigned"homeowner"certifies that he/she understands the City of Salem
Building Department minimum inspection rocedurm and requirements and that he/she
Will comply with said procedures
HOMEOWNERS SIGNATURE
.kppROVAL OF BUILDING CiSPECTOR
See other side for state code
CITY OF S:U Em UkSSAUJUSETTS
7 -sue Rt:tLDL`tG DEP-AA-M&NT
� .. 120 WASHLNGTON STREET, 3w Fti00R
TEL (978) 745-9595
IUIMERL.EY DRISCOLL FJOC(978) 7.10-9334
,bUYo i THo.%w ST.PiERaa
DIRECTOR OF PLBUC PR0PERTY/8t:MDLYG CONNISS[ONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 1 11.5
Debris, and the provisions of tNfGL c 40, S 54;
Building Permit t>t this work shall be is issued with the condition that the debris resulting from
l 11, S I SOA. disposed of in a properly licensed waste disposal facility as defined by itifGL c
The debris will be transportcd by:
r,- M. S i WL. t!f .v w�
(name of hauler)
The debris will be disposed of in
- 3c <L 4.
(name oY Yacility)
(J,tt)res-s or facility) ,
-
.� signaturo of Permit applican \\
date --
i�
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