5 HILLSIDE AVE - BUILDING INSPECTION (5) h
(� The Commonwealth of Massachusetts � TY OF
r Board of Building Regulations and Standards `J Z � LEIvI
Massachusetts State Building Code, 780 CMR Revised blur 2011
N �
\, Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: DateAppheI&
Building Official(Print Name). Signature , Date
SECTION I:SITE INFORMATION'
1.1 Pro er ddress: 1.2 Assessors Map& Parcel Numbers
A//1 � -
L l a Is this an accepted street?yes no hfap Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
"Zoning District Proposed Use Lot Area(sq it) Frontage(IF)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(hI.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yesO
SECTION2: PROPERTY OWNERSHIP,
2.1/qwn t of Rccord�
r City,-one,ZIP
Pr t
asme( ).,osr.le
Nu.and Street
Telephone Email AJdrcsg
SECTION 3: DESCRIPTION OF PROPOSED WORW(check nil that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) 0 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work:
puu�g
>v
SECTION 4:EST131ATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Ite"t Labor and Materials)
I. Building S I. Building Permit Fee: Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical S ❑Total Project Costs(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
d.Mechanical (FIVAC) S List:
5. Mechanical (Fire S Total All Fees:S
Suppression)
� Check No._Check Amount: Cash Amount:_
6. Tot:d Project Cost: S �QU, 0 paid in Full 0 Outstanding Bahmce Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder List CSL'rype(see below)
Type - - Description
No.and Street -
U Unrestricted(Buildings u -to 35,000 cu. Il.
R Restricted I.22 F:unit Dvveliin
City/rown,State,ZIP M Masonry
RC Itoofins Covering
WS Window and Sidin
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Dale
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town, State ZIP Telephone
SECTION 6:WORKERS'COM1IPENSATION INSURANCE AFFIDAVIT(M.G.h 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 AUTHORIZATIONTOBE COMPLETED.WHEN:
:,'
OWNER'S AGENT OR CONTRACTOIC�PPLIES 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 Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the inform ion
contained i plicia n is true and ac to the best of my knowledge and understanding.
rint s cr' gent's Ntunc(Electronic Signature) Date
I. An Owner who o a mg permit to do his/her own work,or an owner who(tires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under NI.G.L.c. 142A.Other important information on the HIC Program can be found at
xeww n1as; eov'oat Information on the Construction Supervisor License can be round at www.mas�
2. When substantial work is planned,provide the information below:
Total fluor area(sq. R.) (including garage,finished basemendatlics,decks or porch)
Gross living area(sq. 11.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
rype ofcooling system Enclosed Open
3. "Ibtal Project Square Footage'may be substituted for,,r,tai Project Cost"
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DUE. F,�'hl".'n�. >ORDER': �J"x'vARi.fi W vBY,
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CITY OF SALEM, MASSAG USE M
BUILDING DEPARTMENT
120 WASHNGTON STREET,3PDFWoit
TEL. (978)745-9595
KIMBERI.EYDRISCOLL FAX(978)740-9846
MAYOR THOMAS STSIERRE
DIRECTOR OF PUBLIC PROPERTY/BUI DING ODhWSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT
Date
Job Location_ 11�rt? -E�-
Home Owner Address vv� le—
Present Mailing Address S o m
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
aIYOFSALFJ14 MASSAQ3Mn
BLBZMDEMFMM err
uows�ar,�i�oax
7kL 745-9M
$i>�BR18Y PAr 74049M
MA]Clt BaSST.P
D ��ac /atta�ara�anaa
Construction Debris Disposo/Affidavit
(required Ibrall demolition and renovation work)
in aocor&=wo the sbA edition of the State MOW Coda, 780aft SecBan 111.5 De N6,
and the proWsias of wi,Go#S 54; "Aft PermitA Is lamed wM the
condtfon that the debris resultbAg hum this work sha0 be dspwed of in a prope*licensed
waste deposit fadlity as defined by A@GI c 111,S 156A.
The debris will be transported by:
(name of hauler)
The debrisviU be disposed of in:
(name of fadllty)
(address of facility `
Signature f plicant
Y V ✓ }
Date