46 LAFAYETTE PL - BUILDING INSPECTION (2) a The Commonwealth of Massachusetts
Boar)of Building Regulations and Standards CITY
r Massachusetts State Building Code, 780 CMR, 7ih edition OF SALEM
Revised JumrarP
Building Permit Application To Construct,Repair, Renovate Or Demolish a /. 100
One-or Two-FomdP Dwelling
This Section For Official Use Only
Building Permit Number: Dale Applied:
Signature: ' a
Building Commissioner/InspectorVIlluildinp Date
SECTION 1:SITE INFORMATION
1.1 Property ddress: 1.2 Assessors Map& Parcel Numbers
`/G / en-"fn.l 9 P R C f
1.1 a Is this an acce led street?yes fy no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Require) 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?
Public❑ Private❑ Check if yesO Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Reco d: n
1 CA L)
Nam P tm) Address for Service:
S a ore Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKr(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Propos Work':
40
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical
❑Standard City/Town Application Fee
S
❑Total Project Cost(Item 6)x multiplier x
3. Plumbing S 2. Other es: S j�
4. Mechanical (IIVAC) S List: � �y [/c 66
5. Mechanical (Fire S
Suppression) Total All Fees:S
6.Total Project Cost: S /t) 0, Op Check No._Check Amount: Cash Amount:
5 13 Paid in Full 0 Outstanding Balance Due:
s e
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL-Ilulder List CSL Type(see below)
r Dewri lion
Address u tlmestricted u to 35,000 Cu.Ft.
R Restricted l&2 Family Dwelling
Signature M Masoary Only
RC Residential Roolin Cuverin
Telephone WS Residential Window and SiJ(n
SF Residential Solid Fuel Humin A liance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
Inc Company Name or IIIC Registrant Name Registration Number
Address Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152.1 2SC(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...........a
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
, 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
ECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the siatemenis,and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury)
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 ld have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.R5, 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 S.u.E.Ni
PUBLIC PROPERTY
DEPARTMENT
.MAYM 130VA91eAGr M IMF1T•swag 4ASAoa'9rTI9 en970
TTi r8.74i9S"• Fax 9'a74a9w
HOMEOWNER LICENSE EXE.MMON
Please"t
Dam -7 1 Y- r 0 Job Laeadw q6 La races ZI� �l/
C, c
Horne Owner Address ,SM, rl� e
Home Owner Telephone ci-7 A Z2 5— L ! 9
Present Mailing Address SScr ,%-k .P
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 act@ as supervisor.
DEFINMON OF HOMEOWNER
Person(#) 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 dwellin& 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 hdshe be responsible for all such wort 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 SIGYATLRE
,APPROVAL OF BUILDfVG NSPECTOR
See other side for state code