359 LAFAYETTE ST - BUILDING INSPECTION r
The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7'"edition Wilbraham
�. Building Dept
)� Building Permit Application To Construct, Repair, Renovate Or Demolish a 413-596-2800
One- or Two-Fanuly Dwelling Ext 118
This Section For Official Use Only
\\�y� Building Permit NumI Date Applied: _ ) 40 ( • O�—�
Signature: 1 b - I - O y
UBut ding Commissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Prop ll�erty Add a s: T / 1.2 Assessors Map& Parcel Numbers
gs9 [ C: s /
1.1a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(R)
1.5 Building Setbacks(ft)
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 yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 yp ce 'o Re ord���4
Name(Print)
(Print) Address for Service:
?2 d, A& / z— c��
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied M/I Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Descrip ' o se k':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
e6 Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 'L L 13 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) n
It /License Number Expiration Date
Nam of SL-Hodder Type/ List CSL T see below)
V� ( ('
AdMs i Type Description
O �5 U Unrestricted(up to 35,000 Cu. Ft.)
R Restricted I&2 Family Dwelling
Signature M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
ml1 n /f ��//� SF Residential Solid Fuel Burning A fiance Installation
J //'/ % D Residential Demolition
5. te 'ste o e a vement o ) D
HI Comp Name or HIC a is ra ame 'Registration Number
Address , �u�
q�` �z� �ryy Expirati n Date
Signature Telephone
S TION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 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 .......... 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.
Signature of Owner Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
1, ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Nam -- _--
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of eriu
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 not 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 110.R6 and I 1 O.RS, 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 coaling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
construction Debris Disposal .affidavit
(reILpuired liar all denwlition and rcno\ation work)
In accurdance ilh the sixth edition of the State Building Code, 780 CMR section I 11 5
Debris, and the provisions of MGL e 40, S 54;
Building Permit rt is issued with file condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal lacility as defined by MGL c
III. S 150A. m
t.
The debris \\till be transported by:
I name of hauler)
I he debris will be disposed of in :
(name tit Luihly)
luddres. tit Ial IIIIVI v
VL'llalUlC �iI pinup applicant
da(c
:} The Conunonweiz&h of Massachusetts
ME
Department oflndus&WAccidentt
ON B1&xallar atloas
600 Washington Street
Boston,Masi 02111
'— Workers'Compensation Insurance Affidavit
- ` ray�J vf�
h ne' O 2e
C j I am a hcmeawn r performine all wore:myself.
�} 1 am a sole proprietor and have no one working in any capacity
!"i I am an emoioyer providing workers' compensation for my emoiovees working on this job.
m anv name,
address-
ohone
'nsurance co aoiicv
i I am a sole proprietor. general contractor. cr homeowner(circle one) and have hired the contractors listed below who have
the foilowine worke s' compensanon ooiices.
ro anv na e-
elm ohone=-
insurance co ooliev4 _
anv na e•
address-
city., phone.-
insurance eo oolicv 4
Farlt rc to score coverage as required under Seedoa 25A of MGL 152 eau lead to the imposition of criminal pea M of a fine rap to SIS00.00 and/or
one years'imprisoament as well as civil pena(Cc in the form of s STOP WORK ORDER and a fine of S100.00 a day against ma I understand that a
copy of this statement may be forwarded to the Once of Invesdgadoas of the DU for coveragt v cadon.
look* by eenify un the p ' d penattirs ofper}try that t info ' n proved ub vve is true and correct
Si
krZ�
Print name d Phone S /) //
�IGrial'use aaty do not write in this area to be completed by city or tawu official
s
city or towu- permiulieenst X r-IBuilding Department
C)Litensing hoard
Q chea if immediate response is requited oselccuoeu's Office
offeulth Department
emiaet persom - phone IS;
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