29 INTERVALE RD - BUILDING INSPECTION The Commonwealth of Massachusetts
# Board of Building Regulations and Standards Town of
? Massachusetts State Building Code, 780 CMR, 7ih edition Wilbraham
Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a 413-596-2800
KYD One- or Two-Fancily Dwelling Ext 118
This Section For Official Use Only
A )x Building Permit Number: Date Applied: ' O O°O
USignature: � b • I • 6p
Building Co missioner/Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 P�o}terty!x s p^� 1.2 Assessors Map& Parcel Numbers
1.Ica Is this an accepted street?yeses_ no_ Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
j Z-4: L �
Zoning District Proposed Use Lot Area(sq f1) Frontage(f2)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required 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 if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP[
2. Owner of Record:
2 9 ,9� iA
Name "tt) Address for Service:
ature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ eAddition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other Speci : _
Brie escription of Proposed Workz61
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $ 12
Check No. Check Amount: Cash Amount:
6.Total Project Cost: S�epO, 11 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL-Holder List CSL Type(see below)
T Description
Address U Unrestricted(up to 35,000 Cu. Ft.)
R I Restricted I&2 Family Dwelling
Signature M Masonry Only
RC Residential Roofing Covering
Telephone WS 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 Dale
Signature Telephone
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 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.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, TE75CIZ '�I� , s Owner Authorized Agent hereby declare
that the statements and information on the foregoing application are true an accurate,to the best of my knowledge and
behalf.
Print N
SiWtu*'orOwner or AutFi- ized Ak6t Date'
(Signed under the pains and penalties of perjury)
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 I O.R6 and I IO.RS, respectively.
2. a When substantial work is planned, provide the information below:
Total Floors area(Sq. Ft.) (including garage, finished basement/attics, 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 for"Total Project Cost"
N
CITY OF $ALE.NI
PUBLIC PROPERTY
DEPARTMENT
K1fOL!�•I tiw•v.
130w.muwerCH SrtFs7•S,u ex MASLACHUSEM 01970
I EL 97a-73S-9S93 0 FAX.978.740.9"
HOMEOWNER LICENSE EXEMPTION
Please Print
Date
Job Location
Home Owner Address _
Home Owner Telephone
Present Mailing Address
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 who.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 betshe 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 understands the City of Salem
Building Department minimum inspection pros ur and requirements and that he/she
will comply with said procedures and r utr en
HOMEOWNERS SIGNATURE 17
APPROVAL OF BUILDING INSPECTOR
See other side for state code