53 INTERVALE RD - BUILDING INSPECTION (2) The Commonwealth of Massachusetts Town of
►, Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, T" edition Building Dept
1V Building Permit Application To Cons epair, Renovate Or Demolish a
One-or co-Fumilr Ot ell ng
is Section For Offic al Use Only
\� Building Permit mbber: Date pplied: 9
�Y Signature: A-A.- gl�IO�
Bull ing Commissi er/Inspector Build Date''
SECTIO 1: SITE INFORMATION
sn ap� Parcel Numbers
1. So� rtVz✓vA .e �d/ 19�;s� 1 O�/
I.la Is this an accepted street?yes Map Number Parcel Number
_ no.
1.3 Z to Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area'(sq R) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
� s 1 1 /� /p 5D1 3� 8O /
1.6 Water Supply:(M.O.L c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
-/ Zone: _ Outside Flood ne? Municipal Von site disposal system ❑
Public❑ Private 14 Check if es
f' , /' SECTION 2: PROPERTY OWNERSHIP' f_ /
2.1 Owner'•oja TA
!V/Z/10 S 66,0 Lc,✓ 4e ✓� tG 7� IkA O//r !1
Name(Print) 'Y' 1 Address for Service:
L=J
Signature Telephone
SE TION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction Existing Building❑ 1 Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ 1 Number of Unit Other ❑ Specify:
Brief Description of Proposed Work': P/W
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building Permit Fee: S Indicate how fee is determined:
I. Building S /Di0007
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S Total All Fees: S
Suppression)
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S r0 O ❑ Paid in Full ❑Outstanding Balance Due:
`7
1
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Numbcr Expiration Date
N�4mc of CSL-Hplder List CSL Type(sec below)
a
Address Type Description
U I Unrestricted(up to 35,000 Cu. Ft.)
Signature R Restricted 1&2 Family Dwelling
M Nlasonry Only
RC Residential Roofing Covering
Telephone W$ Residential Window and Siding
SF turning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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 CONTRACTORR�,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: OWNE t OR AUTHORIZED AGENT DECLARATION
1, f ,as Owner or Authorized Agent hereby declare
that the statements and information on the f regoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name !. /
(�
Signature of Owne or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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 I IO.R6 and I IO.RS, respectively.
2. 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'
i'
162.0o,
LOTS 416, 417, 418 j
AREA = 20,735 t S.F.
- 30. ...�set6ock
f7 U
O
a 'p
o J
N
V
22.0' 36.0' I m
PROPOSED a H
FOUNDATION "
i5' `ront setback
192-70'
NOTES:
-PLAN REFERENCE - PL. BK. 36 PL. 17 INTERVALE ROAD
-EXISTING BUILDINGS NOT SHOWN
' 4 PROPOSED FOUNDATION PLAN
I CERTIFY THAT THE PREMISES SHOWN ARE NOT 'ice y`s 53 INTERVALE ROAD
LOCATED WITHIN A FLOOD HAZARD ZONE AS Y,f, Gxt. A r\ SALEM, MA
DELINEATED ON THE MAP OF COMMUNITY #250102 PREPARED FOR
SALEM , MA. EFFECTIVE 8 5/1985 I" d
BY THE FEDERAL EMERGENCY MANAGEMENT AGENCY. `6, d «, F MATTHEW NICHOLS
1J n _ `` r. ,f , t SCALE 1" = 30' FEBRUARY 24, 2009
` = NORTH SHORE SURVEY CORP.
Fc i.ata '� 14 BROWN ST., SALEM, MA
DA -REG.-PROFESSIONAL LAND SURVEYOR "
978-744-4800 #3225
M1
CITY OF S.0 Y.M
PUBLIC PROPERTY
DEPARTMENT
w�n�t�.Kw.ti
MAWR 130VA"WGU M s"rar 9 SAteK NASAae.'sarts 01970
Tu-VW715-9S" 9 FAL 979•74&9W
HOMEOWNER LICENSE EXEIMM`ION
Please Print
Date C c�
Job Location
Home Owner Addresa -7
Home Owner Telephone
Present Mailing Address :i c,,2,. �s A,/--v. g
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 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR 4�
See other side for state code
CITY OF S.UEM
PUBLIC PROPERTY
DEPARTMENT
iu1n��ivw•n.
130 WARUNM w IMEW•SLLAS M. ASA00.'S M 01970
TeL 970454S"•FAx 97{-740.9e4{
HOMEOWNER LICENSE EXEMM`ION
please Print
Date -
Job Locations
Home Owner Address 1 C.�Xcf'
Home Owner Telephone `l 7 t `t -
prand Mailing Address 1 CeAos
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.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she reside@ 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 procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code