436 LAFAYETTE ST - BUILDING INSPECTION (2) eV
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The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code,78 "3
�J ;��� ��U,,+,';;'."Revised Mm 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
®— One-or Two-Family Dwelling
OTW Section Fpr
str ,lrag p�slt.Number: . DaEe A�pffied: ':
l SEC'Foo 1t SITE II7 0 Ii1TI3N
(1 1.1 P 9r�y
Ad
�rens 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted ?yes_ no Map Number Parcel Number
13 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? Municipal[2 On site disposal system 13
Check Private❑ Check if yes❑
` S>AcrION 2: PROPERTY OWNERSIiI� .. .
2.1=f Recor
Name(Print) City,State,ZIP
N mo d Street Telephone Email Address
SECTION&DESCRIPTION OF PROPOSED WOAW(aback all that apply)
New Construction❑ Existing B�Owner-Occupied 01 Repairs(s) ❑ 1 Alteration(s) Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': O'
SECTION 4:ESTIIl7ATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials
].Building $ 1. BuikHng Peunit Fee:$ Indicate how fee is determined:
13 Standard Cdy/Town Application)zee
2.Electrical $ 13 Total Project Cost'(item 6)x multiplier x
3.Plumbing $ 2. Other Fear:
4.Mechanical (HVAC) $ jG,� j List. /
5.Mechanical (Fire $ Total All Fees:$
S resSion)
Check No. (3teek Amount: Cash Amount:
6.Total Project Cost: $ ��/� 0 Paid in Pall 0 Outstanding Balance Dun:
D
sECI'It)14 5: COMTRUC I7ON SERVIM
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street - Description
U I Unrestricted(Buiklings up to 35 000 cu.R
R I Restricted l&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Pwofing Covering
WS Window and Siding
SF
; -
SF Solid Fuel Burning Appliances
I I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(RIC)
HIC Registration Number Expiration Date
HIC Company Name or BIC Registrant Name
No.and Street Email address
Ci /Town State ZIP Tel hone
SECTION to%VRItEW COMMMAT"VWURANCE AMDAtFIT(ALGA c 152.1 25CM
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...........❑
SSCTI6N is!OWNER AUTftftIXA110N O Alt C()WIXWJ)WIIEN
QWNER'S AAWNT QR GQ _FO ING ITMM
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) Daze
SECTION 7m:0*NER'OR AUTHORIZED AGVN`f DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
conn . eedd.. this application is true and accurate to the best of my knowledge and understanding.
/ \ riotOwner's or Authorized Agents Name(Electronic Signature) ate
NOTES. .._
1. 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
wtivw.mass.eovloca 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 Number of bedrooms
Number of bathrooms Number of half/baths
Type of beating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
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Construction Debris Disposa/Affrdovit
(required forall demolition andrenovation work)
In accordance with the sbcth edition of the State Building Code, 730 CMI, Seclon 111.5 Debris,
and the provisions of MGL coo,S 54; Building Pennit N is issued with the
condition that the debris resuking from this work she#be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111,S 1566
Thedebris willbetransported bey:�(name of hauler) //
The debris will be disposed of in: zzy
2-
(name
(name of facility)
(address of facility)
Signature of ap licant
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QTY OF SALEM, MASSACHUSE TTSBUILDINGDEPARTMENT 120 WASFHNGTONSTREET,3"DFLOOR
TnL. (978)745-9595
KINMERLEYDRISMLL FAX(978)740-9846
MAYOR T}-IOMAS ST.PIERRE
DIRECTOR OFPUBLICPROPERTY/BUILDING CONWSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date 26
Job Location
Home Owner Address Ca ll
Present Mailing Address
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 hire that 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 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 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 understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR