33 HILLSIDE AVE - BUILDING INSPECTION (3) RECEIVED
a,;
the Commonwealth of Massachusetts CITY OF
n Board of Building Regulations and Standards
; � Massachusetts State Building Code, 780 CMR '101b MAR 24 P Vf'I
Revised blur 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling
This Section For Official Use Onl
Building Permit Number., Date lied:
u,, 3 3a b
Building Olticial(Pont Name). Sigoature� Date
SECTION I:SITE INFORiINlATION
t.I ro,arty Address: 1.2 Assessors blop 4 Parcel Numbers
S3 6; IS Ze aNc.
I.1 a Is this an accepted streetT es no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District _- Proposed Use - Cot Ana(sy tt) Frontage(it) .-
1.5 Building Setbacks(R)
. . .. . Rear Yana- .
Front Yard : Side Yards - - "
Required Provided Required Provided .. Required' ' - Provided
1.6 at Supply:(M.G.L c.J0,§5J) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?Public Private Municipal On site Disposal system ❑
CAecklf es
SECTION 2:_PROPERTY OWNERSRtP!
wneri of Record: C l< �a12 r✓\ /h p\ 01 q 7 0
t7ime(Print) City,State,ZIP
q19-7sM(° 56rr'.ct1Stqia4eo.C&A
No an Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction Existing Building❑ Owner•Occupied ❑ Repairs(s) ❑ Alteration(s) :3Addition ❑
Demolition ❑ Accessory Bldg. Number of Units_ Other ❑ Speedy:
Brief Description of Proposed Work':
Xto k QAL 1 001 _
SECTION a:ESTii\IATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials -
I. Building S a 0 v. L Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Tgwn Application Fee
2. Electrical S ❑Total Project Cosh(Item 6)x multiplier x
3. Plumbing S P QtherFees: S
d.Mechanical (HVAC) S List:
5. Mechanical (Fire S Total All Fees:S
Suppression)
Check No._Check Amount: Cash Amount:
6.Total Project Cost S 1 O0 J ❑Paid in Full Cl Outstanding Balance Due:
Mf:N (> 3 ( 3a
`' SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
+-1.-li (,l s y r),j `I t,i License Number Expiration Date
Name of CSL Holder List CSL'rype(see below)
Type Description .
No.and Street
U I Unrestricted(HU11dings tip to 33,000 cu.ft.
R I Restricted M2 Famil [Ave ling
Cityfrown,State,ZIP M Maso
RC Roofina Covering
WS Window and Sidirat
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street - Email address
City/Town, State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION 11 INSURANCE AFFIDAVIT(M.G,L c-M.§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..........O No...........O
SECTION 7a:OWNER AUTHOti12ATIONTO BE.COMPLETED.WHEN
OWNER'S AGENT OR t o I TRACTOR APPLIES 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 information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic 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 Mul have access to the arbitration
- of e-• -
program or guaranty fund under M.G.L.c. 142A.Other important information on iho HIC-Program can be�aind'a1-_--- --- - -
tvtvw mass t:ov;'oca information on the Construction Supervisor License can be found at wwtv.ntas�
2. When substantial work is planned,provide the information below:
"rotal fluor area(sq. ft.) 'x (including garage, finished basementlattics,decks or porch)
Gross living area(sq. ft.) 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 I"ur"Total Project Cost"
QTY OF SALEM, MASSAQHUSE M
BUILDING DEPARTMENT'
120 WASHINGTONSTREET,3" FLOOR
TEL. (978)745-9595
KIMBERLEY DRISCOLL FAX(978)740-9846
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLICPROPERTY/BUILDING COMMISSIONER
HOMEOWNER-LICENSE EXEMPTION
PLEASE PRINT.,
Date 3//Q`1 1I 6
Job Location 33 hhkm'ZG 0.�G
Home Owner Address 33 a Y-.
Present Mailing Address 33 H:m,�c A-c"
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