266 LAFAYETTE ST - BUILDING INSPECTION (2) V !
The Commonwealth ul'Massachusetts
{ Boardul'Building Regulations and Standards CITY
Massachusetts State Building Code. 780 C'MR. 7"edition OF SALEM
'w Revi!'rr/JuIIll1/rl'
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Twu-Family Dwelling
This Section For Official Use Only
Building Permit Nurriber Date Applied:
Signature:
fluildin ommissXwwo Inspector of Buildings owe
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
ac�co Lo-rn�Ae4g-'cN
1.12 Is this an acce teal street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Am(sit 11) Frontage(11)
1.5 Building Setbacks(R)
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 O Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if es0
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Name(Print) Address for Service:
Signature Telephoro
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied O 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.0 Number of Units Other ❑ Specify:
Brief Description of Proposed Work': f"2Q)nrs. S. l Gri.] wa'e'o 4z",
��j to �' C.�r✓l�/ a�' liu�.{�v� Lt>,t1 C/r�oc�. r•2- e�P r'tn �'cnnk c-.r��rl'
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 011icial Use Only
Labor and Materials
I. Building S 1. Building Permit Fee:S Indicate how fee is determined:
O Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (i1VAC) $ List:
5. Mechanical (Fire S
Su ression Total All Fees:S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S ❑paid in Full ❑Outstanding Balance Due:
�2�
I `
c
SECTIONS: CONSTRUCTION SERVICES
7C'S1.-
ruction Supervisor(CSL)
License Number Expiration Date
List C'SL Type(zee below)
f Ihxri ion
U I Unrestricted(up to 73,000 Cu.Ft.
R Restricted 1&2 Famil Ihvellin
Signature M Masonry Only
RC I Residential Routing Covering
I'eleph0ne WS I Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
DTResidentiWn
5.2 Regbtered Home Improvement Contnctor(HIC)
I IIC Company Name or IIIC Registrant Namen Number
Address n Dale
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L e. 152.f 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...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
/ OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
v 1 ',-C�" L:�)c—Ue— i.T) , as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work orized by this building permit application.
Si ore ofDwner Date
SECTION 7b:OWNERt OR AUTHORIZED AGENT DECLARATION
I ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are we and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Own"or Authorized Agent Date
(Signed under the pains and penalties of 'u
NOTES:
1. An Owner who obtains a building permit to do his/her own work, or an owner who him an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will rag 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 790 CMR Regulations I IO.R6 and 1 IO.RS,respectively.
2 When substantial work is planned,provide the intormation 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 SALE.NI
PUBLIC PROPERTY
DEPARTMENT
w� 13e9r.99NGWW SnM•SMAK MwssACHLSE s01970
rEL 97e-7454S"• F.%X 97e-740.9a46
HOMEOWNER LICENSE EXEMPTION
Plsaw Print
Date Paz -1
Job Location ';;Lco c.o Ln yam} Ca"
Home Owner Address
Home Owns Telephone 9-;;p Ss 5T ?9 2`9
Present Mailing Address -Srz� e- -
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
Persons) 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirem
HOMEOWNERS SIGNATURE
.APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SALEM
PUBLIC PROPRERTY
DEI'AK"I'vIENT
r ♦ N%ll \1, \1\„\
11I 'r'9-'li.viai � I \\. `i'% 'J:-'ri J„
Construction Debris Disposal Affidavit
(required lax all demolition :utd renovation work)
In accordance n ill, the sixth edition of the State Building Code, 780 CNIR section 1 1 1.5
Debris, and the provisions of'v1GL c 40, S 54;
Building Permit 11 is issued with the condition that the debris resulting front
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S l50A.
The debris will be transported by:
1 name uF hauler)
The debris will be disposed of in
st (na ne rfacility) _
IadJress ut facility)
.agnartue of permit .applicant
,late