13 LINCOLN RD - BUILDING INSPECTION r (S
h
The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
�i Massachusetts State Building Code, 780 CMR, T°edition
Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling ANNEf
Th s Section For Official Use Only
Building Permit Number: Date Applied: • 2�7'G
Signature: y - S—` QZ
Building Commissioner/ nspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Ads• 1.2 Assessors Map& Parcel Numbers
A 13 4 44- 221
1.1 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 R) Frontage(ft)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 O n r' Re N
13 IwCeI4,61
a e( ri Addressfor Service,
���/ `lo
i nat a Telephone 7d`
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
X New Construction ❑ I Existing Buildingv Owner-Occupied Repairs(s) Alteration(s) Addition ❑
Demolition Accessory Bldg. ❑ Number of Units Other ❑ Specify:
BriefDes 'ption of Propos d Work=: ie
e a J
X
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ e7S0 d 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
X 4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Supression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 0 Paid in Full 13 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)
Type Description
Address
U Unrestricted(up to 35,000 Cu. Ft.
R Restricted I&2 Family Dwelling
Signature M Masonry Only
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
Expiration Dale
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 .......... ❑ No........... ❑
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
1 ( as Owner or Authorized Agent hereby declare
that the stat ncnts and
diinformation
�o-nn the foregoing application are true and accurate,to the best of my knowledge and
Pr ame
Sign Lure o O ner o Authorized Agent Dat
Si ed a der the ains and enalties of er'u
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 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
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF S.U.EM
PUBLIC PROPERTY
DEPARTMENT
K .�s�..,y".•n
Maras 130 wAMDWroM SMEU•SMAK NAUA011.=M 01970
Ta-978-745-9S"9 FAL 971.74&99"
HOMEOWNER LICENSE EXEMPTION
Please Print
Date 23 6
Job Location lei X/l ('c114A
Home Owner Address
Home Owner Telephone
Present Mailing Address Z ID
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 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 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 tyfor 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 INS ECdIOR
See other side for state code
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\\ "':1:911 f 11.\I I \I, \tI'I -
I I I 'I'1 -4; '1411 \5' 'i'$-'4: IS L,
Construction Debris Disposal Affidavit
(required lilr all demolition and renovation work)
In accordance N ith the sixth edition of the State Building Code, 780 C NIR section 1 1 1.5
Debris, and the provisions of'IYIGL c 40, S 54;
Building Permit h is issued with the condition that the dcbris resulting from
this work shall he disposed of in if properly licensed waste disposal facility as defined by MGL c
I11. S 150A.
The debris will be transported by:
(name of hauler)
I he debris will be disposed of in
(natnr of facility)
laddress of tacllity)
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