9 LIBERTY HILL AVE - BUILDING INSPECTION (4) G �
The Commonwealth of Massachusetts CITY OF
a Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One or Two Family Dwelling
v x This SBotton For Officral TJse "ly s
e -1 :e. > n4 °Date-A 1 d
ButldingPermitNumber 6 Pl a
if wig e^h.,fit ,fr k f��j
Buildmg0fficiaL(PnntName), t`, F„sSignature � ; r ,�, `'Date ,,
$ECTION1 SITE INFORMATION `
.1 Property Ar ess• 1.2 Assessors Map&Parcel Numbers
Li he, (l A/z
L i a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ElPublic❑ Private El Zone:
if yes❑
' Si'CTION2:.pROPERTSI OWNERSHIP'k u z ,' r `
2.I_QwneriofRecotd:
L$Qn &m r KvSSej( 7
Name(Pnn City,State,ZIP
No.and Street Telephone Email AddresST �T
SECTION 3 DESCRIPTION.OF PROPOSED WORK2 (check4ll that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
rief Description of Proposed Work : 2 21 e
SECTION 4. ESTFMATED CONSTRUCTION COSTS Zt ,
Estimated Costs: <r 3
Item t� Official Llse Only > 5
Labor and Materials #r
1. Building $ 1 Buildu g PermrtFee $ 3 Indicate how fee is determined r
Stan`da d City Tokyn. . pphcation Fee �,
2.Electrical $ ❑Total Pio3ect Cost (Item 6)xmultipliei r x
3. Plumbing $ 2 Ot}er Fees $
4. Mechanical (HVAC) $ L st
.i. Mechanical (Fire ~£ _
$ Total All Fees $ s " s
Suppression) r. ,, 5 '
Check No Check Amount Cash Amount
6.Total Project Cost: Paid i,hTull ;:y ,❑Outstnnd n9 RalanceDue
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No. and Street Type '.Description
U Unrestricted(Buildings up to 35,000 cu. ft.)
R Restricted I&2 Family Dwelling
City/Town, State,ZIP M Mason
ry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
H
HIC Company Name or HIC Registrant Name IC Registration Number Expiration Date
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 jai OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property, hereby authorize
to act on my behalf, in aft matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
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 understandin .
Print Owner's or Authorized Agent's Name(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 M.G.L. c. 142A. Other important information on the HIC Program can be found at
www.rnass.eov:!oca Information on the Construction Supervisor License can be found at vtwvw.mass.vov%dos
2. When substantial work is planned,provide the information below:
Total floor 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"
CITY OF S.ULB.)O[
PUBLIC PROPERTY
DEPART:tiLENT
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M.1'a.74L91"•F.%L 9'5-7469W
HOMEOWNER LICENSE EXEMMON
Plea" Print
Dat.
Home Owner Addlreaa S R ✓Q
Home Owner Telephone t 6 01,,4
Present Mailiol Address 6-L-,Z
The current exemption of"Homeowners"was extended to inchrde owner-occupied
dwellings of two Units or lee and to allow such homeowners to engage an individual for
hire who does not posses a license provided that the owner acts as supervisor.
DFXIN TON OF HOhMOWNEB
Perwn(s)who owns a parcel o(WW on which hdahe resides or intends to resider on
which these is, or is intended to bp, a one or two family dwelling,attached or detached
structures accessory to such use and/or farm structsnres. 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
Oi'1lcial. 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'certiRe that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures an/dJ requirements.
r
HOMEOWNERS SIGNATLRE
:APPROVAL OF BUILDING INSPECTOR
See other side for state code