4 HILTON ST - BUILDING INSPECTION 1
The Cummonwcallh of Massachusetts Town of
Board of Building Regulations and Standards loossow
a� Massachusetts State Building Cafe, 780 CMR, T"edition Building Dept
Building Permit Application To Construct, Repair. Renovate Or Demolish a
tommodow
One. or ris o-FaindY Divelbng
This Section For ORad Use only
[\
Building Permit umber' Date Applied:
Signature:
Bw mg Commissi r Intpeetar of Bwldmp Date
SECTION 1: SITE INFORMATION
1.1 Property Address•. 1.2 Assessors Map d Parcel Numbers
q isr,r°N ST
i Map Number Parcel Number
I.Is Is This an accented street. yes ✓ no
IJ Zoning Information: 1.4 Property Dimensions:
te La Ana Isq R) Frontage in)
Zoning District Proposed U
1.5 Building Setbacks IR)
Front Yard Side Yards Rear Yard
Required Provided IProvided Required Provided
1.6 Water Supply:(M.G.L e.16,11311 E Flood Zone laformallon: 1.111 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Public O Private O Cheek if veso
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
�FAS/L/k /f� �AtCv/eF—fl i
Name(PP,n9tiy Addttu for Service:
Signature
- Nl Telephone
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction O Existing Building O Owner-Occupied O Repairs(s) O Alteration(s) O Addition O
Demolition O Accessory Bide.O Number of Units_ Other O Specify:
p� Brief Description of Proposed Work': d6zi! to:clb
V
SECTION 1:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Offlclal Use Only
Item Labor and Materials
1. Building f /)'1a`J f- /Yva 1. Building Permit Fee: S Indicate how fee is determined:
O Standard City/Town Application Fee
2 Electrical S O Total Project Cost'(Item 6)a multiplier x
) Plumbing f 2. Other Fed: f
4. Mechanical (HVAC) f List:
s Mechanical (Fire S Total All Fees: f
Su ression
Check No. _Check Amount: Cash Amount:_
J is Told Project Cost f 3JO0 ,nit ❑ Pad ro Full O Outsundmg Balance Due
3
SECTIONS: CONSTRUCTION SERVICES
S.I Licensed Construction Supervisor(CSL)
License Number Espuauon Date
N.yee of CSL Hgkkr List CSL Type(xc below)
AJtkesf T' Description
U I Unrestricted(up to 17.000 Cu. A
R I Restricted l RZ Family Dwelling
signature N I MasonryOnly
RC Residential floofin Covering
Telephone w5 Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Due
Sigtuture Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. ISL# 2SC(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 7n:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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.
signaturvorowner Date
SECTION 7b:OWNERt OR AUTHORIZED AGENT DECLARATION
1, �//L`--/"/W�- On — ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Narro
Signature o(Owner ar Authorized Agent Date
Signed under the pains and penalties ofperjury)
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(nor registered in the Home.Improvement Contractor(HIC)Program),will Mf have access to the arbitration
program or guaranty fund under M.G.L. c. 1 41A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations 110.R6 and 110 R!, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. ft) (including garage• finished basemenVattics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
:N'umber of fireplaces Number of bedrooms
Number of bathrooms Number of half baths
Type of heating system Number of decks/ porches
Tspeof cooling syslern Enclosed Open
I 'Total Project Square Footage"may he suh,muted for 'Total Project Cost"
i
CITY OF SAI_ENf
PUBLI
C PROPERTY
DEPARTMENT
yw,w 130 WA"rK.O snag=•soars.Mwa�oRsarrs 0N'0
ttL s-s +s ss•s •r..�+-s�atiss+s
H0ME0WNER LICENSE EXEMPTION
Pleeu "I
pass o oq
Job Locad" 6( #-IL f-DAI sr-
Home Owna Address a Ff-a-r-o� 5 T
Home Owner Telepbooe y-7& sot v rr a-2 o
Proemt Mailing Address Y t'krc-ro N sr-
The current exemption of-Homeowners"was extended to include owner-0ccupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
hire who does not possess a licensor provided that the owner acts as supervisor.
pEFiNMON OF HONMWNML
Persons) who owns a pared 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 wWor.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 O®cial,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
ill comply with said procedures and requirements.
HOMEOWNERS SIGNAMME
.-kPPROVAL OF BUILDING INSPECTOR z;
See other side for state code
City of Salem, MA 12/10/2009
Parcel Map
MAE&
10 0066
10_0045
10 0065 70-8
2
o_ 46 ., FREOER7Cg St
4
10_0040
I 5 10_ 2,
10_0216
10_01,69 � 1 Vo
v
' 10_0164 ,,, 4 'O2
100214
O
o°,(° 10 o z
0
10_0064 `\ 0
O ,V 65 �OIg9 S 65-S,
0 0213
_ 63 feet 10_0170 3 2
10o Nlk7oly ST
100153
Property Information ❑ Surrounding Towns
Property ID 10_0169 0 ❑ Town Boundary
Location 4 HILTON STREET 0 Ocean
— Streams
MAP FOR REFERENCE ONLY C water Bodies
NOT A LEGAL DOCUMENT ❑ Parcels
— Easement
El Buildings
Bemuse or dRr nt update schedules,cum nt property .. Selection:Parcels
assessments may not reflect recent changes w property
toundades.Check WA the Board or Aseeeeore to mnfi.
Ooundarias usetl at time of esseasment