268 LAFAYETTE ST - BUILDING INSPECTION (2) II The C'ommon weal th of Massachusetts
UUU i� Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code. 780 CNIR SALLM
'L•'.• _
Building Permit Application To Construct, Repair. Renovate Demolish a Reri.red JGm 'lll l
One-or rtvo-Family'Dtrrlthkie
This Section For 01T Use 01
Building Permit Number: le applied: _
Building 011icial(Print N;unc) Signature /D late
SECTION 1:SITE INFORf11A
1.1 ProP k Eperty Address: , .
1.2 Assessors N Parcel Numbers
z c re;" s�
1.la Is this an accepted street?yes_ no_ M1lap Number Parcel Numlxr
1.3 Zoning Information: 1.4 Property Dimensions:
/Doing District Proposed tic Lot Area(sq It) Frontage(11)
1.5 Building Setbacks(h)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40.§Sq) 1.7 Flood Zone Information: 1.9 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check;e —, Municipal ❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownert of Record:
�// ; ° 5c /P .y Ave? O/9 7-D
e(Print) 6—I) SUtc.ZIP
N�6—,,�tia62 ' /-/!' S — -9 �'rF'c�l/��
Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) 0( Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ .Specify:
Brief Description of Prroposed Work-:_�r ,¢c� f— r o rr' c,(
/e Fl SI,Y C l� G T 2c90
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard Cirffown Application Fee
? ❑Total Project Cost'i Item 6)x multiplier
. Plumhi°g S '. Other Fees: S
J. .\lcchanical IH\':1C1 S List:_ _
c \Icchanicad Wire --- ------I S
---
,iression)
.Cu Torai .\It Fees: S —
Total Project Cost: S LLJlJ d Check No. t'heek:lnwunt: - ---__-.Cash :\mouse _ -
0 Paid in Full 13 Outstanding BaLmce Due:
SECTION 5: C'ONS'I'RUC'TION SERVICES
5.1 Construction Supervisor License(CSL)
I.iconse Number-- - -- P\Piralion Dale
Name ol'CSI. I folder
List('St. I')PC(see befoul
__ ------ 'I')PC Description
No. and Street --- —------
U Unrestricted IBuildin gs U to 35,000 ca. It.)
R Restricted lag Famil DNCIIIn
t'lltl foen,`tale.LIt' %I Masonry
RC Roolin C'ovcrin
W'S W'indow:md Siding
SF .Solid Fuel Burning:\ppliances
1 Insulation
I'elc hone I.Anail address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
IIIC Registration Number lispirotiun Uatc
I IIC Compan) Name or I IIC Registrant Name
No. and Street Email address
City/Town,State,ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c. 152. 1 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 ....0..... ❑ 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.
Print Dui e'r's Name(Electronic Signature) Dale
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print owner's or:\uthorired Agent's Name(Electronic Signature) Date
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 no 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
M.ns �; s ,".1 Information on the Construction Supervisor License can be found at t s mass �I � kill,
2. \\'hen substantial work is planned, provide the information below:
Total flour area isq. ft.)_ I including garage, finished basement attics,decks or Porch)
Gross living area I sq. It.) ___ _-_ - Habitable room count
\umber of fireplaces _ Number of bedrooms
Number of bathrooms Number of'holf hails
I\pe ol'heating system -- ... . _ ... Number of decks, porches ._
I)pc ofaooling syswin - _ . . _ Inclosed _ .. .. - _.Open
I
3. 1 oral Project Square Footage'm;q be substituted for"Total Project Cost-
CITY OF $AL.E.Nf
PUBLIC PROPERTY
DEPAR , LENT
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w+'d i]ovw�u+ctaMlnuar�suu�V�aeoaanso»'e
TIM 971045-9s"•FAA 93-740.9W
HOMEOWNER LICENSE EXEM"10M
Please Fs I
Data / O i
Job IAcadom 2i 4 6 S7,
Home Owner Address z 9- L a a -5-0 le-
Home Owner Telephone 8 9 a ,
Prised Marling Address z Co k L a ,-a & W c s ,
The current exemption of"Homeownae was extended to include ownw-occupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
him who does not possess a license provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Persons)who owns a pared of land on which he/she redder or intends to resider on
which them is, or is intended to bs,a one or two family dwelling, attached or detached
strimu m accessory to such use and/or farm structures. A person who constructs more
than one home in a two year period shelf not be considered a homeowner. Such
'tamaowner"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 requirements..
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING NSPECTO
See other side for state code
CITY OF SAL&M, AASSACHUSETi"S
13ULLDLNG DEP.IATONT
120 WmNLNGTON STREET, 3'e FLOOR
h+1 (978) 745-9595
Kl.%®tJtLEY DRl3COLL
FAX(978) 740-9846
,MAYOR 7110-%&U ST.PMR"
DIAECTOA OP PL8t1C PROPEATY/SLQ.DOIG CONOUSSIONEA
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 11 I.5
Debris, and the provisions of MGL c 40, S 54;
Building permit M is issued with the condition that the debris resulting from
(his work shall be disposed of Win properly Iicemed waste disposal facility as defined by MGL c
111, S 150A.
The debris
will be transported by:
ACC% ,' e, e-l- 4 >r,,,.
(name of hauler)
The debris will
be disposed of in :
A
(name of facility)
r' S P o H- Yt .✓
(ju rea of facilny)
fiy% re of permit appliant
U/ - 2 0!
Jute