19 LIBERTY HILL AVE - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
l One-or Two-Family Dwelling
This Section For 'al Use Only
Building Permit Number:'' Oa Applred>;
Building Official(Print Name) Signature Date
SECTION I: SITE INFORMATION '
L1 Property Address: Imo-!/( 1.2 Assessors Map & Parcel Numbers
/O L e-AM4 f' z,--R
L l a Is this an acYepted 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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2:, PROPERTY'OWNERSHH'''
2.1 Owner'of Recordii
49 AO ( F/9V-R ��9 Piwt
Namz(Print) �— City,State,ZIP
No.and Street I/' Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK''(check all that apply)
New Construction Cl Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief D cription of Proposed Work':
aeO4�
SECTION 4: ESTIMATED CONSTRUCTION COSTS-
Estimated Costs:
[rein Official Use Only-,
Labor and Materials
1. Building $ O I I. Budding Permit Fee $ Indicate how fee is determined:
❑ Standard City/Torun Application Fee
2. Electrical S El Total Project Cc ,(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: $ ,t
I Mechanical (HVAC) $ List:
5. Mechanical (Fire $ ��
Snppressioit) Total All Fees: S
Check No. Check Amount•. Cash Amount.
G. 'I'otul Project Cost: S ❑paid in full ❑ Outstanding Balance Doe:
SECTION 5: CONSTRUCTION SERVICES
5.1 Coltstructiun Supervisor License (CSL)
License Number Expiration Date
Name of CSL I10lder
List CSL Type(see below)
No. and Street Type - Description
U Unrestricted Buildin s up to 35,000 cu. ft.)
R Restricted 1&2 Family Dwelling
Cityrrown, State, ZIP bt Lklasonr
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
"relz hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC 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
I, 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.
Print Owner's Name(Electronic Signature) Date
SECTION 7h: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name bel w, I hereby attest under the pains and penalties of perjury that all of the information
contai ed in this. ,tcitioq,is trpe a yocprate tha be oof qty kno.%Aedg.e ancj.understanding.
ritit�wP`,1,44;Author:4&.4gent'sN t• list ua nature �, ,`,,+ „ , \ [late`` s`•
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(H[C) Program), will not have access to the arbitration
program or guaranty fund under A .G.L. c. I42A. Other important information on the IIIC Program can be found at
www.mass.,govioca Information on the Construction Supervisor License can be found at www.mass:•Ov:dm,
2. When substantial work is planned, provide the information below:
Total Moor area(sq. ft.) (including garage, finished basement. tics, decks or porch)
Gross living area(Sq. ft.) _ Habitable room tount
Number of tlrzplaces_ Number of bedrooms
Number of bathrooms Number of hulUbaths
Type of heating system _ ---- Number ordecks/ porches _--
f}'pe or cooling sysizm_ — _ Enclosed-- ------Open . --
�. J_ (bhtl I'rolzct lquurc Pnottge utuy be wb;[ihdad f;or"I}otal Prulect Cost"- . -
t
lid CITY OF S.UXN
PUBLIC PROPERTY
DEPARTMENT
Vwrae I 311 WASOMO 1M Shea*•sALM MAOAOw$m Olt'*
i1tL 1'F745.91 !•F.Aa./'a,7167w
HOMEOWNER LICLNSS EXE.NMIOX
P1saw Trd>.t
Date �� 3
Job Loeadm L v--P
Home Owner
Homs Owner Telephone
Preece/Mailing Address
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or teas and to allow such homeowners to engage an individual for
hire who does not possess a Names provided that the owner act@ as.suparviaor.
DEFINMON OF HOMEOWNER
Person(s) who owns a parcel of Lod on which he/she readdes or Intends to resider on
which there is, or is intended to bs,a one or two dlrmily dw ellin& 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
"homeownal'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
8uilding Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirem ts.
HOMEOWNERS SIGNATL
.APPROVAL OF SUILDING INSPECTOR
See other side far state code
Y I —
1:
�4rr
CITY OF S.-1L, M) -L%LksSACHUSFTi'S
13uLLDLNG DEPARTNLEINT
130 WASHNGTON STREET, w 3 FLOOR
T EL (978) 745-9595
KlmBERLEY DRISCOLL FAX(978) 740-9846
AWOR THo.%w ST.PIEM
DLRECTOIt OF PUBLIC PR0PERTY/BUMD0ZG COMMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovatioa work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5
Debris, and the provisions of ib1GL c 40, S 54;
Building Permit i# 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 MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
_-- (name of facility)
_— (address of facility-- y)
slSnatui a of Permit p leant
date 3/