38 HILLSIDE AVE - BUILDING INSPECTION .s, The Conuuonwealth of MaSUCIIUSMS --—
Board of Butldiog RCgulalionS and Standards I Y )I2
i_ MassaehusettS Slate Buildine Code. 7S(I ('MR, 7 edition NI
• Building PCnnit .\pplieatiun Tu Cunstrurt. Repair. Renovate Or Demolish It R„ n,./huu„u k
tru-FruniADuc1lirr,�
'ihishemon For Official Use Only
Buildnig Permi( Nun er Date Applied:
Budding(', nnus,nmen Inspeemr of Buddmgs Date
SECTION 1: SITE IN'FORNA'FION
1.I�1 roperh Address: 1.2 Assessors Nlap & Parcel Numbers
,j8 or/iCLS/dE �y� ----------
I. la Is (his an accepted street:' yes_ no Map Nunlher P:rr.el ,Number
1.3 Zoning Information: L4 Properly Dimensions:
Zoning District Proposed Use Lot Area(sy it) Frontage I in I
1.5 Building Setbacks(f )
Front Yard Side Yards Rear Yaid
A� Requi rcJ Pmv(JaJ RcyuucJ PnrvidcJ Raymrcd Pro,iJcJter Supply: (M.OQL c. 40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone'' �lunici al ❑ On site Jis>„aal sysicm ❑
Private❑ Check if yes❑ PSECTION 2: PROPERTY OWNERSHIP'
nerof Record:
fi�iGG S "
N c (Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Rep:urs(s) ❑ Aherttion(s) ❑ AJdifion Cl
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Propt ed Work
. �odSrgGL mil-LL�T To E _
SECTION Q: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: — -- --
Item f Labor and Materials) Official Use Only
I. BuildingqCost: $
I. Building Permit Fee: 8 Indicate hosr fec.(. de"11uncd:
❑ Standard City/Town Application Fee
2. Electrical ❑Total Project Cost' (Item 6) x multiplier x _
i. Plumbing '. Other Fees: '6�
4. Mechanical List:5. Mechanical Sur ress(on) Total :\II Fees: S
Check No. Check Arm unt: ('ash :\nn*tun I
�0 Polal Proje �OO 0Pail in Full ❑Ou(arutding B.J:uxe Due:__ -.--
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Cmtstruction Supervisor IC'SIJ j
I_Ic:nNe Number -- — u\PII.w)m D.ae x�
..\ame ))t l'S1.- IIuIJrr ---
LolC'-I. 1\Ix•t"I hrlu)%I
J
\JJIe» 1. l IueNlrli led nI' n+ is.IN1U Cu I'L 1
---- R Restricted I&' FuutlN Docltiti,
il_n:nurc ,M \l anon rs Only
RC Re'IJ:ntlal Ruulin�(\)':nm`
I cleph)we \\S Resldenl 1.11 NI lid...� .Ind ilJw—e
SF Ri.IJeutial Sulld I I)cl 8tutull__ \L ixl" lu.l.�l l,ll1, n_y
D Re'ldtnt)ul Delnulm"11
5.2 Registered Home Itnpruventent Contractor 0II0 - -1
ItIC Cuntp:my Nanm or HIC Registrant ?lame — —� Reeuuauun Nulubcr— __ ___
Address
Fxpuaw)n D.ue —�
Signature Trlcphune I
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6)1 i
Workers Compensation Insurance affidavit must be completed and submitted with this appliratinn. F;ulure ta) pn)\ide
this affidavit will result in the denial tit the Issuance of the building permit.
Signed AffiJ;tvit Attached? Yes .......... ❑ No .-.-._. ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, _ as Owner of the suhlect property hereby
1 authorize -__-- to art in my behalf. in all ntauers �
re:atr:e to %vork authorized by this building permit application.
Signature of Owner - Due
SECTION 7b: OWNERt OR AUTHORIZED AGENT DECLARATION
1• le5-0 %ETSa.J , as Owner or Authorized Agent hereby Jeclare
that the statements and information on the foregoing application are true and uccui ate. to the best of my knowledge and
behalf.
1�
Signature M Owner or Authorized Agent Date
I Signed under the pains and penalties of perjury)
NOTES:
I. An Owner who obtains a building permit to Jo his/her own work. or an owner who hires an Am egiste,ed runt,ecru, l
(nut registered in the Home Improvement Contractor (HIC) Program), will not hace access to the uhal ai It n
program or guaranty fund under M.G.I_. c. IJ_'A. Other important information on the HIC Program and
Consnwion Supervisor Licensing (CSI_I can be tmind in 780 CMR Regulations 110.R6 and 110R5. ,esp"ti%cly.
' When substantial work is planned, provide the Information below:
Total flours area!Sq. Ft.l fmcluding garage, finished basemenVattics, decks nr porch)
Gn)ss h%,mg amea ISq. F'I.)_ Habitable room count -
Number of tlreplaces Number of hednnnns
Number of bathownis _ Number of hal l.'h.nh, -_
hype tit heanniz system _ Number otdeck,/
I mie of cooling system _ Fnclused
i. "total Project Square Foolage• may be submiluted for "'total Prof"( Cost— ---
CITY OF S UXUM
PUBLIC PROPERTY
DEPARTMENT
K11WEilLY evw•n. . - .,,
MAvaa 130 WA9aNGTM Sn=U•SJUSK MAS A00.'LTM 01TM
T a:TWUS-9S"* FA1c 976-740.""
HOMEOWNER LICENSE EXE.IMMON
Please Print
Date 9
Job Location s8 ,yiGGS/�E /�dE SftG�Jl/ lylli9 ,
Home Owner Address 19'
Homeowner Telephone
Present Mailing Address -T .V1Z/ 5/DE
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
hire who,does not possess a license,provided that the owner acts as supervisor.
DBFiNMON OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on
which that is, or is intended to be, a one or two family dwelling attached or detached
strictures 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATUREZ
APPROVAL OF BUILDING INSPECTOR
See other side for state code