28 LAFAYETTE PL - BUILDING INSPECTION �I
Ma- 2) S S 20 i -1
The Commonwealth of Massachusetts 7fUyise"2"
U
Board of Building Regulations and Standards '.PCT� ALEM
Massachusetts State Building Code, 780 CMR Building Permit Application To Construct,Repair,Renovate Or DemhW
Q One-or Two-Family Dwelling
Q This Section For Official Use Only
Building Permit Number 'Date Applied:
11
Bmidmg Official(Print Name) Signature. Date
SECTION 1:SITE,INFORMATION
'
1. Pry7 erty Address: 1.2 Assessors Map&Parcel Numbers
Icfl M_-FAz6Trf 8ACZ
L L I a Is this an accepted street? es 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 yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 wnert of Record:
� Name(Print) City,State,Zte�, IPIP` aF z&21& 2r mx/gssF
No.and Street Telephone Email Address c
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of ProposedWork�: 7-6-A 4iv /lcc/hO�fL
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
Labor and Materials
1.Building $ 1. Bailing Permit Fee:$ Indicate how fee is determined;
2.Electrical $ ❑Standard City/Town Application Fee
(7 Total Project Cost?(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
`^ 4.Mechanical (HVAC) $ List L
5.Mechanical (Fine Su $ Total All Fees:$
ression
Cbeck No: Check Amount: Cash Amount:
F.Total Project Cost: $ 95a40 ❑Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
KT Consfructfon Supervisor License(CSL)
License Number Expiration Date '
Name of CSL Holder„', ' -
- •t List CSL Type(see below) ,
No.and Street Type _:Description,. -
U I Unrestricted(Buildings up to 35,000 ca.ft.
R I Restricted L@2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding 'i
SF Solid Fuel Bunning Appliances
I Lvsulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name -
No.and Street Email address
City/Town, State,ZIP Tel hone
SECTION 6:WORKERS°COWENSATION INSURANCE AFFIDAVIT(ALGJ- 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,.hercby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b OWNER'OR AUTHORIZED AGENT DECLARATION
- By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
cont aine li ah n is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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
finny mass.gov.'oca Information on the Construction Supervisor License can be found at www.mass.gov/dns
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 heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
?1
!.� QTYOF SALEM, MASSAMUSETTS
1 BUILDING DEPARTMENT'
120WASHINGTON STREET,3ftORom
TEL. (978)745-9595
FAX(978)740-9946
K11vIBERL.EY DRISOOLL
MAYOR 7!IiOMAS STTIERRE
DIRECTOR OF PUB LICPROPERTY/BUILDING COM7,USSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT.
Date �'-Ae — 16
Job Location_ c)-O L f
lael
Home Owner Address 62, oL/g`�y
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
Ch YOF SALEIV4 MASSAm EEM
BEUZMDEPAaMWxr
120 WasaR C KSUMT,3ADA00it
113E 078 745-9595.
Fex(M 0.9816
%IMBERLEYDRLSQ7LL
MAYOR NCUASSTTAM
DntEcrcitcpPuujcpyzfmy/Bumnmamamcmm
Construction Debris D1spos17/Aff1dav1t
(required for all demolition and,.renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMRi, Section 121.5 Debris,
and the provisions of MGL M, S 54; Building Permit#t is Issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MAGI. c 111, S 1SOA.
The debris will be transported by.
�O�S DiS�o�C
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
Date