312-312 1-2 LAFAYETTE ST - BUILDING INSPECTION The Commonwealth of Massachusetts
} Board of Building Regulations and Standards CITY
�� 1•!t Massachusetts State Building Code, 780 CMR, Ph edition OF SALEM
'w Revised Jumrury
Building Permit Application To Construct,Repair, Renovate Or Demolish a 1. 2olhY
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Num r. Date Applied: - '�, )
Signature:
Building Commi o er/ ns for of Buildings Date
SECTION 11 E IPIFQRMATION
1.1 Property Addrey: i Map& Parcel Numbers
I A Is this an accepted r ?yes no �Q/M#Numbcr Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq f1) 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❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes13
SECTION 2: PROPERTY OWNERS Pt
2.131^nert of Re�iwvc 6 9A44 9J 0
Name(Print) V 0 Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S Q Q. I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (tIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
2 Check No._Check Amount: Cash Amount:
6.Total Project Cost: S �� UUU`' O Paid in Full 0 Outstanding Balance Due: _
i r
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) ds�j36� 7
rn1�d License Number E. Pint n Date
Names � tIfolde " r ,,,. List C'SL'rype(see below)
Address fl(Jely T Descri tion
„ p U Unrestricted u to 35,000 Cu.Ft.
/vim-- R Restricted 1&2 Family Dwelling
Sig %rc r I/ M Mason Onl
`-� rGLJ RC Residential Rootin Coverin
relephone WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home improvement Contractor(HIC) 1K -,
1IIC Co�pprt� ggrr IIIIC Re istrant I� Registration Number
dd YY �
Address f Expiraefort D m
Signature U 'relep one
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 Issu ce of the building permit.
Signed Affidavit Attached? Yes.......... No...........O
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.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
d as Owner or Authorized Agent hereby declare
that the statements at ' formation on the foregoing application are true and accurate,to the best of my knowledge and
behalf. k
QIU) J rh or p
Print Nam
Signature of Owner or A rized Agent Date
(Signed under the pains and penalties of 'u
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&gJ 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 110.115.respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage,finished basementlattics,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
J. "Total Project Square Footage"may be substituted for"Total Project Cost"
I
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. :• 12 Thompson Rd Webster.
i ,training SCertiOcate of Atteadance�annd
Successful Completion
_ Renovator Refr74 et
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Childhood Lead Poisoning Prevention Program
MemberofCONEST
yLEAD ABATEMENT CONTRACTOR
BRIAN MOORE
License#: DC-219
Expiratroo ,a"
._ :..� Joss-Thier7 obir c Health
Division of Public Hearth
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i NOT A LEGAL FORM OF ID
Vat,.. 'm . .» �1 t..aahu .it flap r t nail ut Public ti ifc[� .
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Bond ut Bwldin,, Ra u4 tiuul rod �Ctodurti.
9 u
m ructniha5 i, Prvt.,nrr L:iren5
tii :•' License. CS 54380
^ Restricted to: 00 _
BRIAN J MOORE
•' m 34 SHIRLEY LANE
wN� i Q' SHREWSBURY, MA01545
�2 00 '` ,.ri>� �- �';%�„� Expiration: 7/24/20t0
Tr#: 29274 ..
Ars, 1
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�S CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
II.\1.;0.N5I'NL•rT 4 SA 1%1, M.Ni\I I II d 11 :I'1
IFI:47/•74 9i95 • 1:\8:978•740-1846
Construction Debris Disposal Aftidavit
(required Ilar all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # _ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
I11. S 150A.
The debris will be transported by:
I name of hauler)
The debris will be disposed of in :
(name of aci Ity)
t: rcsc of Nciliryl
Nip(namre of permit applicant
date
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