5 LIBERTY HILL AVE - BUILDING INSPECTION 2-(o�7 - 14 4�-A5�H q0
The Commonwealth of Massachusetts
� Board of Building Regulations and Standards CITY OF
f ALENI
Massachusetts State Building Code, 780 CMR Sd
Revised,1far
Llnr 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
Z One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: b'ateAp !j .
Z
Building Official(Print Name). nature Date
SECTION L SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
j L,-6 AvA
1.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(IL)
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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check ifyes❑ Municipal ❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP!
2.1 Owner'of Record:
N c EtiO 10 M r r � o f , n��n,Ar 191.9 z 0
iJhme(Print) City,State,-LIP
5 id�, be.aH �+,,(1t�-e 9799-14 dDa-7 0C-w, 1.,.-..� 61Urn ;/- COV .
No. m Strcet Telephone Email AddresV
SECTION 3: DESCRIPTION OF PROPOSED WORK=(chec ll that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alterations) ElAddition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units J- I Other ❑ Specify:
Brief Description of Proposed Work': -r-b,q ' S tea-P-!'t..-tv._I `I' S "�._
SECTION a: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
Labor and Materials)
1. Building $ S—f 0617_t9_t7 I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee .
2. Electrical $ -
❑Total Project CosP(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $ C- /\
4. Mechanical (HVAC) S List: (�
5. Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6. 'total Project Cost: S St 0 0 Paid in Full 11 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL"Cype(see below)
No.and Street Type Description:
U Unrestricted(Buildings tip to 35,000 cu. ft.)
R Restricted 1&2 Family Dwelling
Cityfrown,State,ZIP M Masonry
RC Routing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
FIIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State ZIP 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
L as Owner of the subject property,hereby authorize
't4 act on my behalf,in all matters relative to work authorized by this building permit application.
e Cam` E(
l'nn Owner's Name(Electronic Signature) Dale
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION-
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Natne(Electronic Signature) Date
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 lvLG.L.c. 142A. Other important information on the HIC Program can be found at
www.mass.,>ov;'oca Information on the Construction Supervisor License can be found at www.mass.eov'dns
2. When substantial work is planned,provide the information below:
Total Floor area(sq. ft.) (including garage, finished basementlattics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces dumber 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`"rota) Project Cost'
CITY OF S.U-EM
PUBLIC PROPERTY
DEPAM,[ENT
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ML 9,8415-91" a t+,ts#78.714964
HOMEOWNER LICENS8 E.Xj.MFrIOV
Plisse Print
Date a
Job Laeatfan S i —f^f ! 7/ q e &c1 L_t 1, A-t,A 9 r4 o
Home Owner Address Jam.,, _o G r G I n.A
Home Owosr Telephone 9 7 g Q z9 — p a,-7
Pseud Mailfa#Addrae
no current exemption of"Homsowaas"was estmded to include owner-occupied
dwellings of two Unite of few and to allow mete homeowners to eagsge Me individual for
hire who does not possess a 11cmK provided that the owner acts as supaWsm.
DEFINMONOf HOMHOWM
Persona) *be owns a pateel of laod on which hdshe reafdee a intsrsds to tx!dde, on
which them I; of Is intended to b;,a one.or two tlmily dweWng, attached or detached
structures accessory to such use and/or firm stiucturea, A person who constructs more
than one home in a two year pafod shall not be considered a homeowner. Such
"homeowner"shall submit to the Building OU'fcisi, on a town acceptable ro the Building
Official, that he/she be responsible for all such worst performed under the Building
Permit
The undersigned "homeowner"assumes responsibility for compliance with the Slue
Building Code and other applicable by-lawn and regulations.
The undersigned "homeowna"certilles that helshe undentands the City of Salem
Building Department minimum inspection procedures and requirements and that hdshe
.vill comply with raid procedures and requirements
HOMEOWNERS SICNA TL'RB
kPPROVAL OF 9UILONG INSPECTOR
See 0tha side far state tole
♦� 1
...�a�r CITY OF SA F-.Nl, NLxsSACHUSETTS
131 LMNG DEPARTMENT
N 120 WASHIINGTON STREET, 3° FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
(QABFRt F-Y DRISCOLL
i�L�YOR THOSG►S ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDNG CM IISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by N1GL c
111, S 150A.
The debris will be transported by:
,� Imo-r—V�d�-ele_ Ce✓��f
(name of hauler)
The debris will be disposed of in :
(name of facility)
(address of facility)
i ff nn
signature of permit applicant
a ? /I _
date
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