215 LAFAYETTE ST - BUILDING INSPECTION The Commonwealth of Massachuscus
Board of Building Regulations and Standards CITY
VIV Massachusetts State Building Code, 780 C'MR, 7'edition OF SALEM
RevireJJmnrsvv
Building Permit Application To Construct, Repair, Renovate Or Demolish a
1 or Two-Fumi1v Dwelling
I Ihis Sestion For ORicial U nl
Building Permit Number: Data Ap ed: 4O 0
Signature: /D /V
Building Commissioner/Inspector of B ild' Date
SECT :SITE INFORMATION
I.I rty Address: C / 1.2 Assessors Map& Pared Numbers
.a;is 14-Rz4e Me _ tXd`h„_
I.la Is this an accepted street?yes ✓ no Map Number Parcel Number
13 Zoolog Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lol Area(sq Il) Frontage(it)
1.3 Building Setbacks(R)
From 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 D Private 0 Zone: _ Outside Flood Zone? Municipal D On site disposal system D
Check if es0
SECTION 2: PROPERTY OWNERSHIP'
Olepert Rf Record (S l �n p/�jtGflo/QJ tl--�/�c�e TY1�Q/a Or /--E-r (�r-12�� (.!'r`,
Name1P ' 1) /(, � Addr5safar �v�ice: -4 20
Sign re Telephoro
SECTION J: DESCRIPTION OF PROPOSED WORK'(cbeck aB that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) D Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg.0 Number of Unit_ Other D Specify:
Brief Description of Proposed Work: t✓ 00 ,
G C jM
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost: OHlclnl Use Only
Labor and Materials
I. Building S 1. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S 0 Standard City/Town Application Fee
O Total Project Cost'(Item 6)x multiplier x
1. Plumbing S 2. Other Fm: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
suppression) la l All Fees: S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S
j'D 0Paid in Full ❑Outstanding Balance Due:
SECTION S: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number lapiroliun Dule
Name ol'CSI.• I lulder List C'SL Type Isee below)
f I Oescriolion
:WJreas U I lnreslricted(up to 75,000 Co.Ft.
R Restricted 132 Family Dwelling
Signature I M I lviasonry Only
RC Raidenital RoutingCovering
I"cicphrme WS Residential Window and Siding
SF I Residential Solid Fuel Illumine Appliance Installaliun
D 1 Residential Demolition
S.2 Registered Home Improvement Contractor(HIC)
I IIC Cum Name or HIC Registrant Name Registration Number
Address Expiration Dam
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.IL e. IS2./ 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..........0 No...........O
SECTION 7n:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I , 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.
Si ore of Owner SECTION
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
i as Owner or Authorized Agent hereby declare
that the statemen an information on the foregoing application we true and accurate,to the best of my knowledge and
behalf.,—
Print NameT
Signature of Owner or Authorized Agent Date
(SivAed under the oains and penalties of '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 Zg 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 MRS.respectively.
Wham substantial work is planned,provide the information below:
Total floors area ISq.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 hall)baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
). "Total Project Square Footage"may be substituted for-Total Project Cost"
,. 1,11 Y l )t' OALLIVIL
�; PUBLIC PROPRERTY
'� DEPART WENT
Construction Debris Disposal Affidavit
(rcgitiled ti,r ❑II den tohtlolI iund rcnovatikill work)
In accordance %c ill, the sixth edition of the State Building Code, 780 CAIR section 1 1 1.5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit it is issued with the condition that the debris resulting from
this work shall he disposed of in it properly licensed waste disposal facility as defined by MGL c
t 1 1. S 150A.
The debris will be transported by:
titanic of hauler)
I he debris will be disposed ot'in
(uamr ul laei rty)
t;ulJrcs. ul 16c,lityl
_ . gnat re ut p:Wait.y,phcanl
.late
CITY OF S.ULEM
PUBLIC PROPERTY
DEPARTMENT
ww. �ao v�uMcror.snasr�s�ua VwsuoRssrn ots-o
rat-9-6.749.9s"•FAX r.11.7+4-e9y
HOMEOWNER LICENSE EXEMPTION
PIM" "t --
Date
Job[oeados /.��l?�fe r/r ✓i'
Home Owner Address ss
Home Owner Telephone P7,,I- gft .5=�e ,
Presses Mailing Addeeae cry,,* �
The current exemption of"Homeowners"was extended to include owneroccupied
dwellings of two Units or less and to allow such homeowner to engage an individual for
hire who does not possess a license6 provided that the owner sets are supervisor.
DEFINMON OF HOMEOWNER
Person(s)wbo owns a paned 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 understands the City of Salem
Building Department minimum inspection procedure and requirements and that he/she
will comply with said procedure and requirements.
HOMEOWNERS SIGNAM E
APPROVAL OF BUILDING DiSPECTOR
See other side for state code