5 HILLSIDE AVE - BUILDING INSPECTION (4) /3 �, I'he C'unununwcahh of Massaehuscus
Board of Building Regulations and Standards CI'I'1. OF
s Massachusetts State Building Code, 75O C NIR SALEM
t
Building Permit Application To Construct. Repair, Renovate Or Demolish a
lbre-ur r1v114'oni1Y Du.dligp
This Section Fur Ot33cial Use Onl
Building Permit Number: Da Applied:
— -
Building OlTicial(Print Mane) Signature V Bme
SECTION I:SITE INFORMATION
L I Property Address: ,/ A�V 1.2 Assessors Slap S Parcel Numbers
f-�� fC._
I.la Is this an acre ted street? yes no Map Nunnher Parcel Numher
1.3 Zoning Information: 1.4 Property Dimenslam:
Zoning District I'ropuscd Ilse Lot Area Oil 11) Frontage(11)
1.5 Building Setbacks(e)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required 1rovided
1.6 Water Supply:(M.G.I.c. 40. §54) 1.7 Flood Zone Information: tM,
wage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? i al❑ On sitAp D" )
C esk il' cs❑
SECTION2: PROPERTY OWNERSHIP'
1 Ownern of Record
a 3�i-"t a
N;unc(Print) City.State.ZIP
5 �`-L�tar� �..)� G1Z8•-7'f'o.0'-l9
No.and Street relephone Finail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Aherotianls) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specity:
Brief Description of Proposed Work^ o v S
SECTION 4: ESTIMATED CONSTRUCTION COSTS
I1e1tt Estimated Costs: Official Use Only
(Labor and\Lmerials) y
I. Building S 3 p pp , °° 1. Building Permit Fee: SU."' Indicate how lee is determined:
'. Flectrical S ❑Standard City Tuwn Application Fee
❑Total Project Cost'(Item 6).x multiplier _ x
1. Plumbing S '. Other Fees: S -- -
J. \IcJmnicai ill\.\('1 S List:
5 \l"11,11nical (fire - _.-...__ . . . .
1tiplvvssioni S Tafal .\II Fces: S_ __
Check Vat. ('heck:\nninnrt: _ Ca)h \mount:
o Tulal Project Cost: i 000, ❑P;nid in Full ❑lhnsrmJing Bul:mcc Doc:
VA ��
r^ ,
SEC IONS: CONSFRUct-IONSERVICF.S
5.1 C'onstructiott Supen isor License(C'SI.I
I ieense Nunihcr Pipir;uinn ))ate
I is l'SI. I)Pe I�ee hduiv 1-__.
I)Pe Dcicripliun
Na .mJ tilrecl
U VnresriaeJllluilJin i tin to 15,11110cu. IL1
R Re rictcd Ilt P.unil - Dnellin
Cigil'aSlata{II' \I Mason
RC R,N)hn Uncrin
%kS R'induw;mJSidin
.— SF Sulid Fuel Ihming Appliances
I Insulation
'felt bona Email address 1) Demolition
5.2 Registered home Improvement Contractor(HIC)
( � IIIC Rcgistrutiun Nwnhar li.cpirutiun Duty
I IIC C'anipan) Name or I IIC egisqu Litt
ti -
No. mid Sire¢ O Emull aJdress
City/Town, State,ZIP fete hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e. 152. § 23C(6))
Workers Compensation Insurance afFldavit must be completed and submitted with this application. Failure to provide
this aflldavit will result in the denial of the Issuance of the building permit.
Signed AlMdavit Attached? Yes .......... o No...........O
SECTION 7s: 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 Dinner's Nmne(ElccmIDlc 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.
1-4 LC,na4 L IZIV-UI 3
Print 1)iiner'i ur:\utharind,\gcnt's NLune Ililectnntie Signature) Date
NOTES:
7su—bstanlial
r who obtains a building permit to do his.her uwn work,or an owner who hires an unregistered cuntractur
tered in the Hume Improvement Contractor IHICI Program),will no have access to the arbitration
or guurant) fund under M.G.L. c. 11_'.a.Other inipurtant information on the HIC Program can be found at
. �,ii . ,.i Information on the Construction Supervisor License can be found at o)i,i nLi.; !o% 'Ili'
bstantial work is planned,provide the inlunnatiun below:
a I sq. A.) - i including garage, linished basement amen,decks or porch)
Grosi living area t sq. I),) _ _ _ - Habitable count count __. ,... . ..
Number olbedrooms - -. .. . .
\um her ofhathroms . . _ Numberofhalfhathi -
I\pc of haatiog i)rlctn Nmnhcr of Jecks, pordics
1'\I,a of eooling ')item I!nelPicd .,Open
t "fnlal 11wivo Square footage"ma) he suhstituwd I'or"fol;d Project Cost-
EJ
CITY OF S.U-&Nt
PUBLIC PROPERTY
DEPARTMENT
ku.a.aasr wsra�+
sores t]0vAonw-Uw!suer•swumVUM660 sLMaOtto
M 1'LIJs9stf•VAL 13-7g9eN
HOMEOWNER LICENSE EXE.MMON
Phrase"I
DW
Job Locados � 1 vreu U
Home Owner Address_ A5 ia-.cs_ i5 v or
Home Owner Telephone fl-7Q—
Presses Mailing Address -Zrf�A, �J&
Tits current exemption of"Homeowner"was extended to include owner-occupied
dwellings of'two Units or less and to allow such homeowners to engage an individual for
hire who.does not posses a license provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s) wile owns a parcel of Ind on which hdshe 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 ardor 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 Ofllcisk on a form acceptable to the Building
Official, that hdshe be responsible for all such work performed under the Building
Permit
The undersigned "homeownee assume@ responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner"certifies that h lshe understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requir ts.
HOMEOWNERS SIGNATURE
.APPROVAL OF BUILDING NSPECI'OR
See other side for state code
CITY OF S.1L. mj ttiLUS.ICHE;SETTS
E3L'tLOLVG DEP.1ATtEVT
I .0 WASHLNGTON STREET, J`FLOOA
trr. ���� 74s•9595
u�®f1lLBY oIeLSCOLL P.kX(973) 74498U
.MAYOR MO.wd ST.PmUA
DIAECTO4OPmaLic PROPlA7Y/eCmnojG COIaIIsstONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 790 CMR section I l 1.J
Debris, and the provisions of MGL a 40, 3 54;
Building Permit is is issued with the condition that the debris resulting from
This work shall ba disposed of in a properly licemed waste disposal facility as defined by NIGL c
111. E 130A.
The debris will be transported by:
(n,+me of'houler)
The debris will be disposed of in :
(name of fudily)ly)
<;;;::W AJ--f PS r- T,�
( Jdrar of ftrihty)
to of^ it ipphcint
,4a