8 HILLSIDE AVE - BUILDING INSPECTION (2) 10q L `7 Z.c» "S-M
The Commonwealth of Massachusetts i f d B E1vD
� oar o Building Regulations and Sta CITY OF
G ��CT10l1A1 SER ICES
yl/ Massachusetts State Building Code, 780 Sr\LEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Reno wtt�JP��isfAl 4E1
One-or Two-Family Dwelling 1L1tl1
'this Section For Official Use Only
Building Permit Number: Date Applied: oe
�1
J Building Oflicial(Print Name) Signature to
SECTION 1:SITE INFORMATION
l LI Prope•ty Address: 1.2 Assessors Map& Parcel Numbers
r— I.I a Is this an accepted street'?yes ✓_ no Map Number Parcel Number
T` 1.3 Zoning Information: 1.4 Property Dimensions:
Toning District Proposed Use L.ot Arco(sy IQ Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided 1equired 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'?
Check it'yes❑ Municipal ❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
Z� Owner'of Rec 1: n
Ilc �no�S 1J'' o
Name(1' orrmt) City. State.ZIP
_ 1�.,-
No.and Slid "telephone Finn it Address
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction ❑ Existing Building Owner-Occupied H% Rcpairs(s) vbrl .lu,tian(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify:___
Brief Description of Proposed Work 2:__Ple��e__S __
SECTION 4: ESTIfNmTED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
I. Building $ I. Building Permit Fee: .$ Indicate how fee is determined:
2. Electrical $ ❑Standard Cityfrown Application Fee
❑"fatal Project Cost'(Item 6)x multiplier_ x
3. Plumbing
_. Other Fees: $_
4. Mechanical (I IVAC) $ List:
5. Mechanical (Fire
Sun ression) $ Total All Fees: $_
Check No. __Check Amount:_ Cash Amount:
11
6. Total Pro eel Cost: $ O6U 0Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor rtLicense(CSL)
���lUq.i 'A+101T License Numher Expiration Date
Name of CSL Holder
d ;p Af r }� �'^p List CSL Typc(see below)
No.and Street 4 Y3 Type Description
U Unrestricted(Buildings Lip to 35,000 cu.11.)
Citylfowo,State,ZIP
R Restricted 1&2 Farnily Dwelling
M Masonry
RC Rooting 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 I-lIC Registrant Name
No.and Street
Email address
City/Town,State,ZIP "fete hone
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 PEWMIT
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: 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 true and accurate to the best of my knowledge and understanding.
�Q,.,� U t7 N 6z�_lg
Print Ow is or Authonz 1 Agent's Name(8lectronic 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
(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
www.ntass.aov/oca Information on the Construction Supervisor License can be found at www.mass.Rov/dins
2. When substantial work is planted, provide the information below:
Total floor area(sq. 11.) (including garage, finished basement/attics,(leeks or porch)
Gross living area(sq. R.) 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
;�S � °7T
J sI^ .t l BUILDING DEPARTMENT
>� - J 120 WASHINGTON STREET,3ftD FLOOR
\.�c*'t' TEL. (978) 745-9595
FAX(978) 740-9846
KINiBERI.EY DRISCOLL
MAYOR Tmv As ST.P1ERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONME SSIONER
_HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date O uk'' II aa �+ ��
Job Location Yi q.65 �J`�,,II kte J / YYf O N 7 0
Home Owner Address � th,/ltSlx l� c 1'/ cw� ?o
Present Mailing Address q- 10 S�& /r v W 4 c)1.570
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'
CITY OF S:�LE'Nfl L%CkSS:ICHUSETTS
�\I ` OLILONG DEPARTMENT
�i.:r ,.• l30 CV.1$HLNGTON ST zFET, Jw FLOOR
eti,_• `v ry T IL.. (973) 745-9595
KI1t➢ERL-EY MUSCOLL FAX(973) 7-10-9345
,bL-kYott
T'-tascU sr.Ptzvis
DIaECCOa OF Pt:3L[C PROPE"tTy/aL:UMLYG COJL'tt55[ON EX
Construction Debris Disposal AFtIdavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CLMR section it 1.5
Debris, and the provisions of tb(GL c 40, S 54;
11 Building permit 1#1 is issued with the condition that the debris resulting from
l 1, S I SQA. f i
work shall be disposed on a properly licensed waste disposal facility as defined by tN(GL c
'['he debris will be transported by:
ti �S rti �
(name ufttautcr)
The debris will be disposed ot'in
(rsune of tacilrty) —"
1
---(�Jdress of tiici4 !)
iignatureut'permitapplicant �
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