20 INTERVALE RD - BUILDING INSPECTION The C'onnno"'"ahh of Massachusetts
Board of Building Regulations and Standards CITY OF
'r Massachusetts State Building Code, 780 CMR SALEM
Building Permit Application 'ro Construct. Repair, Renovate Or Denwlish a
\ flue•or 71tw4lunilm Du•e/fi))1V
/ I this Section For Official Use Onl
Building Permit Number: — Date Ap lied:
Building 01171cial(Print Muriel Sign Baas
SECTION I:SITE INFORDIATION
1.1 Prop Address:
O ✓dress: 1.2 Assessors ►Iep d0 Parcel Numbers
1.1 a Is this an acre ted street?yes no 11,1ap Number Parcel Number
1.3 Zoning Informatlon: 1.4 Property Dimensions:
tuning District fmp.,cd U,c Lot Area IN 11) frontuge(11) '
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.a0,§5a) 1.7 Flood Zone Information: 1.8 Sewage Dlsposel System:
Public❑ Private O Zone: _ Outside Flood Zone?
Check:r.—❑ Municipal❑ On site disposul syitem ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownera (Re ord:
l r'�Ji t <E—
City.Slate.LIP
L EAA�E ��� r � � �Lfs`/
No.anJ�arect Telephone Finail Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O L Existing Building❑ Osvner-Occupied ❑ 1 Repairs(s) ❑ Alteratfon(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Spccily:
Brief Description of Proposed Work=: Z�
12
SECTION 4: ESTIMATED CONSTRUCTION COSTS
liens Estimated Costs:
(Laborand.\laterials) OMCIAI Use Only
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
'_. Electrical S ❑Standard City?own Application Fee
❑Total Project Cost'(11em 6)x multiplier x
?, I'lumbing S ?. Other Fees: S
I a, >ledmanical ill\ \('l S List:-- --___
S. Mechanical iFire
Cu vcssion) S Total \I Fces: S
o. Total Project Cost: S Check Vu. _ _('heck Am ('ount: _ -- ,ash \mount:
���,8U ❑ Pail in Full O Oulstanding Ilalance Due:
SECPION5: CONSTRUCTION SERVICES
5.1 Construction Supervisor license(C'SL)
I icensc Number --. _.._ I vinaiou Date
Natle al 0l. I Iuldcr -
I oil C'SI. i)pe hx
__ _-_.-__.-- l\Pt' Description
inll Street U Uarestnelcd(Ihmildin s ti to 15,000 al. It
It Restricted Ilt2 FJltill 1 13\\cil"1
l'igil'o\\n,Slale,LlP \t Masan
RC Rt%)lin(01%crin
..._. \\'S Window and Siding
SF Solid Fuel Iluming Appliances
I Insulation
1'ele hone I'.ria,I address D Demolition
5.2 Registered Home Improvement Contractor(IIIC)
I IIC Registratiun Nunnher Fspiration Date
I IIC C'ompan) Name or IIIC Registrant Name
No.and SUM Email address
Ci /Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,e. 152.1 25C(6))
Workers Compensation insurance affldavit must be completed and submitted with this application. Failure to provide
this atlidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... 0 No...........0
SECTION 7a: OWNER AUTHORIZATION TO OF C0111PLETED WHEN
OWNER'S_AG ENT ORCONTRACTORAPPLIESFORBUILDINGPERMIT _T—__
I,as Owner of the subject property,hereby authorize
to act an my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Nanie(Electronic Signature) Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below. I hereby attest under the pains and penalties of perjury that all of the information
in this application is true and accurate to the best oFmy knowledge and understanding.
coot 'n PP /
Print Owner's or Authorise Agent's Nome( .Ibectronmc Signature) Date
NOTES:
I. :\n Owner who obtains a building permit to do his.her ov n work,or an owner who hires an unregistered contractor
(not registered in(he Hume Improvement Contractor(HIC) Program),will1 have access to the arbitration
program or guaranty I'unJ under M.G.L.c, la_.>. Other important information on the HIC Progr
am can be round at
nm.m••, .•O\ 01 1 Information on the Construction Supervisor License can be found at
3 \\'lien substantial work is planned,provide the information below:
rota) Iloor area(sy. R.) - ____-._(including garage, finished basement attics,decks or porch)
Gntsslising area Isy. 11.) _-_- Habitable room count
\umber of lircplaccs .... Number of bedrooms
\Innher a(hmhrowus . . \umber of half bolo ..
I\Ile at heating syaem Number of decks. porches
i _
\lie of caalnl_L' i\ilen) Enclosed .,tlpell
1. "1atal I'rojcct Square Footage-nla� he substituted litr fatal Project Cost'
r
CITY OF SAI.E.II
PUBLIC PROPERTY
DEPART--ENT
�u.autar o�ernu
wva. t b v�w.K.,oM sna=r�sw.w�.aeoaa„s osr.o
nL si�t,s ss"•v..x r.s.7,o9sw
HOMEOWNER LICENSE EXEMPTION
Plea"Pullet
Dan
Job Loeadois 0 _ +�(-U Cd E,Fj
me
Ho Owner Address _
75 et
me n Ho Ows T hon elepe
Ptesemt hRailimg Addrees E � v
rr
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units at leas and to allow such homeowners to engage an individual for
hire who.does not possess a Hceu%provided that the owner acts as supervisor.
DEFINITION OF HIO&MOWNER
Pemon(s)who owns a parcel of land on which he/she resides or interds to reside.on
which there is, or is intended to be,a one or two family dweWng,lunched or detached
structures accessory to such use xWor farm shuctum 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 workperformed under the Building
Pamit
The undersigned"homeownee assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner''certilles that he/she understands the City of Salem
Building Department minimum inspection procedures and req ' cnts and that he/she
will comply with said procedures and redlujifernenits,
HOMEOWNERS SIGNATLIE7-6G11
APPROVAL OF BUILDING CISPECTOR
See other side for state code