6 MAPLE AVE - BUILDING INSPECTION 4 The Commonwealth of Massachusetts
\ ' Board of Building Regulations and Standards
Town of
Massachusetts State Building Code, 780 CMR, 7"edition Wilbraham
Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a 413-596-2800
ne- Two-Fancily Dwelling Ext 118
Thi Section For Official Use Only
Building Permit Nu r. Date Applied: 40, t�
c
Signature: O�j_
B il ing Commi'sione I pe or of Buildings Date
SECTION l: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
I.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 uire
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 O On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 ner'of Record: (�
IrPORq) ( (no
Name(P pinm[-)r' Addreses for ervi7 -7 / Q eg J
�u� -tom /Zf.W�/� G /1 t_
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Ili I Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Ed Addition ❑
Demolition ❑ Accessory Rldg. ❑ Number of Units Other ❑ Specify:__ -
Brief Description of Proposed Work'-: OO
PD
\ �
u e VQ
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 000 I. Building Permit Fee: $ Indicate how fee is determined:
D Q O ❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $ _
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ JJ 000 0 paid in Full ❑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)
Address Type Description
U Unrestricted(up to 35,000 Cu.Ft.)
R Restricted 1&2 Family Dwelling
Signature M Masonr Oulu__
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
E;:pimtien Date
Signa urc 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, Geo 1. L/ go lJ (J as Owner of the subject property hereby
authorize f 1 V,; to act on my behalf, in all matters
relative to work authorized by tht building permit application.
Si nature o�Of ner Z Date
SECTION 7b:: OWNEW OR AUTHORIZED AGENT DECLARATION
I, G eo RU e :?(Z O j r _ _,as Owner or Authorized Agent hereby declare
that the statements ztnk information on the foregoing application are true and accurate, to the best of my knowledge and
behalf
Go Gov A
-Print Name /p1
Signature of neror uthorize gent Date I/—V
(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 I I O.R6 and 110.R5, 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"
CITY OF S
.1LE.Ni
PUBLIC PROPERTY
DEPARTMENT
KI jawA."DAML v L -
7Vi 97e-74S.MS • F.%X 976-740-984
HOMEOWNER LICENSE EXEM"ION
Please Print
Dace b
Job Location#-6
Home Owner Address 11 t u
Home Owns Telephone 617 1710
Present Mailing Address A.P
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
him 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 mom
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. ` 1•,�
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 46� 'L�s
APPROVAL OF BUILDING LNSPECTOR
See other side for state code
CITY OF SALEM
/ors `A PUBLIC PROPRERTY
: > • .'1_
DEPART LIENT
construction Debris Disposal Aftidav it
(1'ellttl1Cd l'or all dCI11ol1I1J11 :old renovation work)
In accordance \\ith the sixth edition of the State Building Code, 7S0 CI 1R section 1 1 I S
' Debt is, and the provisions of AGL c 40, S 54:
Building Permit it is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal I'acility as defined by vIGL c
I I I. S 150A.
The debris will be transported by:
GP\, FsM
I name of hamcr)
I he debris will be disposed of in
taJJrr.• ul Ixilnvl
HL'I WInKo p:nntt .q±plicam
,late•