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23 LAUREL ST - BUILDING INSPECTION w 1� 33- Diol / a The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY Massachusetts State Building Code, 730 CMR, 7ih edition OF SALEM ,h f Revised January Building Permit Application To Construct, Repair, Renovate Or Demolish a /, :OON One-or Tivo-F mt1.v Dwelling This Sec on Vor Official Use Only Building Permit Numbe/ Date Applied: Signature: DQC Z 3 7—o16 Building C ntissioner/l6soector of Buil s Dale — ECTIO [:'SITE INFORMATION i 1.1 Propey Address: �/J 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 Il) Frontage(it) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water upply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage DlAposal System: Zone: Outside Flood Zone? �/ Public Private❑ Check if yes❑ Municipal On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner ofRecor : �- S�vrNtwsd< Nam rit ) Address for Service: S �^ /k Z— Signature Telephone SECTION 3: DESCRIPTI N OF PROPOSED WORK=(check"at apply) New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) Erl Alteration(s) Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work': Jt ^� — lyeuy S c-P-P-! Gy lis.. S Z r SECTION 4:bt 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building S 4yn 6 I. Building Permit Fee: $ Indicate how tee is determined: ❑Standard City/Town Application Fee 2. Electrical S '.5 Q6� ❑Total Project Cost'(Item 6)x multiplier x 3. ['lambing S S b� - 2. Other Fees: S 4. Mechanical (IIVAC) S List: 5. Mechanical (Fire S Suppression) Total All Fees:S Check No._Check Amount: Cash Amount_ 6.Total Project Cost: S 30t Q00 ❑Paid in Full ❑Outstanding Balance Due: 30 � y a10 w SECTION 5: CONSTRUCTION SERVICES 5,1 Licensed Construction Supervisor(CSL) �I v r License Number Expiration Date Nanrc of CSI:I lolder .�6. pl 09h�v1, �Lll1— List CSL 11pe Isco below) LrZ Description % d, lj ,S .r„ ` Il Unrestricted a to 35,000 Cu.R.) It Restricted 1&2 FamilyDwellin Signature ,y�62 _� fr M Masonry Only RC Residential Routing C'overin I alephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation U Residential Demolition .r 5.2 Registered Home Improvement Contractor(HIC) t I IIC Company Name or Ii IC Registrant Name Registration Number Address Expiration Date Signature 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 ..........0 No...........0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, , 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. Signature of Owner Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION S/�00,7 S K ,as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf. 1 , Print Name / ` /Z-/Z / Signature of Owner or Aut rized gent Date (Signed under the sins a enaltics ofperjury) NOTES: I. An Owner who Wtains 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 trot 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 110.115, 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 half7baths 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 SALEM, ANSSACHCSETI'S Bl;ILDIING DEPARTMENT ' 130 W.1.SHLNGTON STREET, 3iD FLOOR TEL (978)74S-9595 FAX(978) 7449846 KiN®FRi RY DRISCOLL ,1TAYOR THO.�us ST.PtEaas DIRECTOR OF FLUX PROPERTY/81LAMNIG COMMISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 1 I l.5 Debris,and the provisions of MGL c 40, S 54; Building Permit# 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 bx: (name of hauler) The debris will be disposed of in : { / (name of facility) , (address of facility) signature of permit applicant 2 �© dal d.brwtf d.k l