9 LAURENT RD - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards Tow nof
( r y Massachusetts State Building Code, 780 CMR, 7'"edition Building Dept
`-� Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Arco-Familt,Dwelling doom
This Section For Official Use Only
Building Permit Num r: Date Applied: Q
Signature:
(r Sn
Building Commissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
X1.1 Property Address: 9 (5k J cer1A D 1.2 Assessors Map& Parcel Numbers 7\
1.la 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 n) Frontage(it)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Requircd Provided Required Provided
1.6 Water Supply:(M.G.L c.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public O Private O Zone: , Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 (;wner'of Record* i
Nano(Print} Address forr Service:
�LlS
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Alteration(s) Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units 2 Other O Specify:
Brief I}escription of Proposed Work': Z,
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
1. Building S I. Building Permit Fee: S Indicate how fee Jdetermined:❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier Plumbing S 2. Other Fecs: 5
4. Mechanical (HVAC) 5 List:
5. .Mechanical (Fire5
Su ression Total All Fees: S6. Total Project Cost: SCheck No. Chcck Amount: Cash Am
f\ ❑Paid in Full O Outstanding Balance Due:
i
r `
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
• License Number Expiration Date
Name of CSI. Hplder List CSL Type(see below)
Address RDResIdential
Descn tion it
ricted u to 35,000 Cu. Fr)
cted 1&1 FamilyDwelling
Signature ntial Rocfin CoverinTelephone ntial Windowand Sidinntial Solid Fuel Bumin A liance Installation
Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC 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 .......... O No........... ❑
SECTION In: 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:OWNER' OR AUTHORIZED AGENT DECLARATION
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.,
b� o L
S;LA7 c
tLo—
Signatureof Owner or Authorized gent Date
(Signed under the pains and penalties ofperjury)
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 g(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 IO.R6 and I IO.RS, 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
J. "Total Project Square Footage"may be substituted for 'Total Project Cost"
CITY OF SALEM
. ry PUBLIC PROPRERTY
�• . 4
♦ /fin.
DEPARTMENT
III )'S '4i \\. �i'N '4:'/i L,
Construction Debris Disposal Affidavit
(rcyuired bur all demolition and rcnuvatiun work)
r
In accordance a iIIi the sixth edition of the State Building Code, 780 CNIR section 111.5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit N is issued with the condition that the debris resulting from
this work shall he disposed of in a pruperly licensed waste disposal Iacility as defined by MGL c
I11. S 150A.
The debris will be transported by:
tnamc uChaulcr)
lite debris will be disposed of in
Ls _
(name ul lacifity)
(addres, of tucliav)
11gliarturc olI nit applicant
T
late
CITY OF & I.EM
PUBLIC PROPERTY
DEPARTMENT
Klld�cv n�wvv
NwYOM
130 1YA411MVZ'gJ SIfm•SMEM.NA4Adl'SE'riS 01970
741 r6.74S.9S" *FAY.978-740964
HOMEOWNER LICENSE EXEMMON
Please Pratt
Date (0 D
Job Location ISA a 2E^y-t-' R-0
Home Owner Address t5i0rm r--
Home
Home Owner Telephone 9-7 46 7 4C — V Z 72_
Present Mailing Address :11
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or less and to allow such homeownen to engage an individual for
him who,does not possess a license,provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to resi4 on
which them is, or is intended to be, a one or two family dwellin& attached or detached
structures accessory to such use and/or fano 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 hdshe 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
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE
.APPROVAL OF BUILDING INSPECTOR
See other side for state code