5 HILLSIDE AVE - BPA 12-1052 REDECK v
I'hc C'ummumec;lldt of blassarhusc(Is
y; Board u(13uilding Regulations and Standards CI'i'h' OF
r a Massachusetts State Building Code, 780 LAIR ti,\Lli,\I
J
Building Permit \ppiication 'ro Construct. Repair, Renovate Or Demolish a
Ow-or rwo-k'amilr Dtrellim,,'
This Section For Official Use Only
Building Permit Number: Date pplied: 4 _
' ,,-,Idd�
Iluilding 0113cial(Print None) Signature Dulc
SECTION I: SITE INFORIIIATIO
1.1 PrMperty Address: 1.2 Assessor bias S Parcel Number
I.la Is this an icce ted street?yes no flap Numlvr Parcel Number
LJ Zany; L fonnutlon: tz" 4 Properlmenslam: /
Coning District I4roposcd Usc Lot Area(sy 11) Frontage(it)
1.5 Building Setbacks(It)
Frunt Yard Side Yunis Rear Yard
Required Provided Required Provided Required tt Provided
" � N A
I.ti Woter Supply:( .G.I.c.J0.§SJ) 1.7 Flood Zone Information: 1.8 Sewnge Disposal System:
Public❑ Private O Zone: _ Outside Flood Zone? Municipal❑ On site disposal s)stem ❑
Check if es0
SECTION1. PROPERTY OWNERSHIP'
2. Ownert of Reeord;
�vc e.K L �T2Z`7 "sLcx (�::' Ci1— 1 .
Nanw(Print) City,Stale,ZIP
3 I-lf� �stot� . •��� JV-�4o-0490
Nu.:i td Swet - relephune Email Address
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) O 1 Alteratlon(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg, ❑ I Number of Units_ I Other ❑ .Specify:
Brief Description of Proposed Work': o-%/
— `
L—K.0
SECTION J: ESTLNtATED CONSTRUCTION COSTS
Neill Estimated Costs: Official Use Only
(Labur and Materials)
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
'. Iaeclrieal S ❑Standard City To%vn Application Fee
❑Total Project C'ustn 1 hem 61 x multiplier -- .x
1. 1'lunihing S '. Other Fees'. S
J. \Icdianical ill\ W) $ LisC -
�u arc i.umn rrdai .\II Fccs: _----
_ CltecA \u. ( heck :\nluunt: _ t'.uh \nuiunl:
o iblal Project Cost: ) '300
O, ❑ Paid in Full 0 Oulsnading B.nl.ulce Due:
SE(JI0N5: C0NSFR(1(-n0NSFRVI( FS
5.1 C'unstrucliun Supervisor License I(`(•1
I jcoise Number F\Iiiratwit DAV
\anw of(SI I loldcr I is[ (W I,ev Klima
-,--— -— - - . I)PC Description
No, ind Nircet it I IfirvStrioct.1(Iluddings tp it).15,000'u, It I
lic,tridcd Ira? Pamil Do cilia
Alison
RC Rimilill C--itilr
A S 'Xindow aq
SF Solid Fuel Ilumink Appliances
I hisulution
D Demolition
I Himil addrt;m
5.2 Registered Home Improvement Contractor(111C)
=��7
IIIC Regibiraliun Number F\pirulitln Date
I IIC Compio) Movie or I IIC lielli Nome
No. wad Street limail address
FiT(T—own.State,Zfp Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e. 152. 1 ZSCM)
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 or the building permit.
Signed Affidavit Attached? Yes .......... a No...........0
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1. as Owner or the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Umivr's Nurne(Electronic Signature) Date
SECTION 7b:OWNEWOR AUTHORIZED AGENT DECLARATION
By entering my name below. I hereby attest under the pains and penalties of perjury that all of the inrormatican
contained in this application is try and r toth estorn nowledge and understanding.
r.4"r it"
Print 0%%ner'.i tic.%%illikiriivd, cutinic Sigmatire) Date
,NOTES.
I \n Owner%%hu obtains a building permit to do his her own work,or an owner who hires an unregistered contractor
I not registered in the Hume Improvement Cuntnictur I HIC) Programi, will!U) have access to the arbitration
program or guaranty fund under.M.G.L. v. 142A. Other important information on the HIC Program can be Bound at
\%\%,% ,,r., o% , , i Information on the Cunslruction Supervisor License can be round at %l wl it.i,;
2. %\lion substatilial%%ork is planned, provide the int'urmation below:
rota) (lour area(iq. 111 1 including garage, tinished bascmellLatficS,decks or porch)
Gros lie ing area 154. 11.1 flabimble count couill
\tall her offircplai:cs Number oftict.1roomi
Nuillherot hathroulill 'suillber ill hall,hall1i
llcoflicmillg lstimberot'decks liorl;hvi
I,e "I'looling is item IIICIPsed Plwil
I oi,ii It rot co Squort: I:ooi.wc-ma.s t,e titi,itittick] 111r 1'ol,il Proico CoNt"
CITY OF S.U.E.N(
PUBLIC PROPERTY
DEPAMtENT
u,u•a�s+r o•eu,u
` A °e t>s��•wcrou srfaan• aaa N�oR suss Ol f'e
TtL f"tit+ifSf! • t+.uL f'b7a49W
HOMEOWNER LICENSB EXENUMOV
Pleasw Foist
Dar.
lob Laeaticis 5 ►wSt t� a�i ti �L
Homo Owner Address 5 L s ► ,�,
Home Owusr Telepbene !a - - ai
Preset Madiag Address -� r-, —c,►®rz_ -�", 7 C,4c_�tia r Ir( /l
The current exemption of 'Homeownere was extended to include owner-occupied
dwellings oft" Units or teas and to allow such homeowners to engage an individual for
hire who dos not possess a licanso provided that the owner acts as supervisor.
DEFQ MON OF HOMSOWNEA
Persons) who owns a pared o/Lod on which hdshe resides or intends to redde. on
which there is, or is intended to bs, a one or two family dweWngs attached or detached
structures accessory to such use and/or rum struotuna. A person who conswicta more
than one home in a two year period shall not be considered a homeowner. Such
-homeowner"shall submit to the Building Oillcial, on a forth acceptable to the Building
Official, that hatshe be responsible for all such work performed under the Building
Permit
The undersigned "homeownd'assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undeni greed "homeowner"certifies that he/she undentands the City of Salem
Building Department minimurn inspection procedures and requirements and that he/she
Will comply with said procedures and requirements,
HOMEOWNERS SIGNAMM
kPPROVAL OF SUILONG MPECTOR
See other side for state code
r
C[n of 5.u.E.tir, Akss.tCHUSETTS
JLMDcvG 0Ev.1RnLE.`T
I .0 W-UN6VGTON JrXW, 1'O FtOCII
ILrL k9711) 741-9591
KIMBPRLBY DRISCOLL P.Vt(973) 110.9844
MAYOR I}IaxwST•Fm "A
D tAE=it Oip pL aLtc PROpLrATY/at:anINC GO\pllsstON ER
Con9truction Debris D[sposal Affidavit
(required for all demolition and renovation work)
rn accordance with the sixth edition orths State Building Code, 790 CMR section 1 11,S
Oebris, and the provisions of,MGL c 40, S 34;
Building permit a is issued with the condition that the debris resulting from
this work shell be disposed of in a properly licemed waste disposal facility as defined by NIGL c
11 I, S 110A.
rho debris will be transported by:
(n4m0 ofhauler)
The debris.will be disposed of in :
/ (n.me of fuiA�ly)/
1,ddr.tr ar r,il �y)
tnuureof;,er