4 PLEASANT ST - BUILDING INSPECTION (3) :r
L ZS 0-0 75
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
VE� ,
Massachusetts State Building Code,780 CNIR
Revised.Nnr 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date I Applied:-
[Suilding Oftcial(Print Mane). Sigitatpre - - Date
SECTION G SITE INFORMATION
.1 Property AJdress: 1.2 Assessors Map& Parcel Numbers
5' PL;rty;= sr / S A-LE-M
I.l 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 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Rcquired 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 O On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
Pfr-HteD Le'a )rS SA LErtA MA- d743-0
.tRshme(Print) City,State,ZIP
#- P1-c'✓C,4rvT- j< r q�? 9987,o3o r/ewis P)Sa/em5t-c.¢e, edo
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK](check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work--
//V57+44--L SIW4i-6 SHt D OAJ PR0 E0eTtq
/ zc : x /0 * .
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/'Gown Application Fee
2. Electrical S
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: .$
4. Mechanical (HVr1C) $
List:
5. Mechanical (Fire S
Suppression) Coed e111 Fees:S
Check No._Check Amount: Cash Amount:_
l/� 6.Total Project Cost: $ 2300 — Cl Paid in Full 13 Outstanding Balance Due:
s
SECTIONS: 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 tip to 35,000 cu. It.)
R Restricted 1&2 Family Dwelling
Cityffown,State,ZIP =DDemolition
Roofing overin
and Siding
l Burning Appliances
Telephone Email address n
5.2 Registered Home Improvement Contractor(HIC)
f lIC Registration Number Expiration Date
f IIC Company Name or f IiC 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
t9 act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's None(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 understanding.
Pc14-)ten L r uns 7 S
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 in unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program),will not have access to the arbitration
program or guaranty fund under NI.G.L.c. I42A.Other important information on the HIC Program can be found at
www.n&tss.',ov"oca Information on the Construction Supervisor License can be found at www.mass.gnrddps
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 hcating 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.ULE.N1
PUBLIC PROPERTY
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HOMEOWNER LICENSE EXEMPTION
AN" Mat
Data /o
Job I ocadom Z1- PC 6- Fm.4 Aj r S r S'-1-L f wi vtq It
Hama Owner Addtlese s n m c-
Homy Own•:TelepbOne ? 9LS 9 9 8 2050
Presort Mailing Address 4 V<<�ts-1A,r s r s I c t'p" su,t 4 }0
The current exemption of"Homeownere was extended to include owneroccupied
dwellings of two Units or leaf+and to allow such homeowners to eagags an individual for
hire who does not possess a licenser provided that the owner acts as supsevisor.
DEMMON OF H0M80WMM
Person(s) who owns a parcel o(WW an which he/she resides or intends to resider on
which there is, or is intended to be,a one or two Btmily dwelling,attached or detached
structures accessary 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
Otlleial, 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 bylaws and reguladons.
The undersigned "homeowner'certifies that he/she understands the City of Salem
8widinll Department minimum inspection procedures and requirements and that he/she
.vill comply with said procedures and requirements.
HOMEOWNERS SIGNATLRB
APPROVAL OF BUILDING OiSPECTOR
Sce other side for state code
4 PLEASANT STREET 335-14
Gis#: i1969' COMMONWEALTH OF MASSACHUSETTS
fi i i,Hs. •.L
Map." 36 "
Block: 801 . CITY OF SALEM
Lot: 0444-801
Category: INSTALL SHED
Permit# 335-14 1 BUILDING PERMIT
project# JS-2014-000794
Est. Cost: $2,300.00
Fee Charged: ' $25.00
Balance Due: $.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: "' Contractor: License: Expires:
Use Group`. ' HOMEOWNER
Lot Slze(sq.ft.); 0
, Owner: LEWIS RICHARD A,LEWIS EMILY
Zomng ;; .F
's Applicant: LEWIS RICHARD A,LEWIS EMILY
Units Gained:
Units Lost: . u 4 AT: 4 PLEASANT STREET
Dig Safe#:
ISSUED ON. 23-Oct-2013 AMENDED ON: EXPIRES ON. 23-Apr-2014
TO PERFORM THE FOLLOWING WORK
_ INSTALL SMALL SHED ON PROPERTY (SIZE: 8' X 10')
k:w POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Electric Gas Plumbing Building
A'lh
Underground: Underground: Underground: Excavation:
r
Service: Meter: Footings:
Rough: Rough: Rough: Foundation:
Final: Final: Final: Rough Frame:
Fireplace/Chimney:
D.P.W. Fire Health
Insulation:
Meter: Oil:
Final:
House# Smoke:
Water: Alarm:
Assessor Treasury:
Sewer: Sprinklers: Final:
;.THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIOLATION OF ANY OF ITS
aRULES AND REGULATIONS.
. ..
Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
BUILDING REC-2014-000796 23-Oct-13 1375 $25.00
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