379 LAFAYETTE ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts F
O
Board of Building Regulations and Standards CITY ITY
vlassachusetts State Building Code, 730 CMR SALEM
Revised,Wur?011
a
Building Permit Application"Co Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Building ORiciul(Print Name). Signature Dat
SECTION 1:SITE INFORMATION'
j0I.I Pro ertzY Address: 1.2 Assessors Map&Parcel Numbers
C A Fa el k S�
1.1 a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
ZoningZwtingpistrict Proposed Use Lot Area(sg11) Frontage(11) \
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided I
Required Provided Required Provided
1.6 water Supply:(b1.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal don site disposal system ❑
Public❑ Private❑ Check if es❑ p p y
SECTION 2: PROPERTY OWNERSHIP!'
2.1 Own eR cor: ?,eV?, S 94l/eoi / ry/A 019
}me(Print) City,State,ZIP �?
'37q Ll`168, I-+e S I-. �7&'. 1-/o�139117 J_P_e9 '5 (0AhW,Q
No. and Street I Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alterntion(s) V1 Addition
Demolition Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Grief Description of Proposed Woro-: r dd
o /r1�6 'JI N
SECTION 4: ESTIMATED C NSTRUCTION COSTS
It` t Estimated Costs: Official Use Only
Labor and Materials)
I. Building $ 00O I, Building Permit fee: Indicate how fee is determined:
❑Standard City/Town Application Fee
3. Electrical S ❑Total Project Costa(Item 6)x multiplier x
J. Plumbing S ?. Other Fees: S
4."'lechanic:d (HVAC) S List:
5. ;Mechanical (Fire � futdl All Pees:S
Su t trcisiunl
10 WO Clteck No._C'heck Anwont: Cash Amolult:
6.Tulal Pro
ject Cult: ' `� ❑Paid in Full 0 OuGtanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Nantc of CSL Holder List CSL Type(see below)
Type Description
Na. and soot
U Unrestricted(Buildings tip to 35,000 cu. It.)
It Restricted l&2 FamilyDwelling
City/Pawn,State,ZIP M Masonry
RC Rooting Covering
WS Window and Siding
i
SF Solid Fuel Burning Appliances
I Insulation
'I'Vie hone Email address U Demoon
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Comp;my Name or 111C Registrant Name
No.and Street Email address
t City/Town,State ZIP rele hone
SECTION 6:WORKERS'CONIPENSATION INSURANCE AFFIDAVIT(NI.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 72:OWNER AUTHORIZATION.TO BE COMPLETED.WHEN.
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize J—f-FF P--e f,&S -
t9 act on behalf,in all e s relative to work authorized by this building permit application.
Print OwiilytoA
Electronic signature) Date
I
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 a plicatiot ' r e and accurate to the best of my knowledge and understanding.
Print 0 ner' ur Au orizcd r gcnPs N:unc(EIecU tic Siymuve) Date
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 hlome Improvement Contractor(111C) Program),will 1L)i have access to the arbitration
program or guaranty fund under M.G.L.c. I42A. Other important information on the HIC Program call be found at
w ww.mass. vL 4:!UGt Information on the Construction Supervisor License can be found at www.mas._ov'Jps
' 7. When substantial work is plumed,provide the information below:
Total floor area(sq. It.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. 11.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
type of heating system Number of decks/porches
l'ype orcoolin�,,system f_nclosed Open_
4. • Iwal Projst square Footage"stay be substituted for-rutal Project Cost'
-- °�r , CITY OF SALEM, MASSACHUSETTS
1.. �` BUILDING DEPARTMENT
,in '� !' 310 FLOOR
asi -�";fps; 120WASHINGTONSTREET,
\' �::', . TEL. (978) 745-9595
��"-`'°`P� FAX(978) 740-9846
KINMERLEY DRISCOLL
MAYOR `I�-IOMns ST.PIERI�
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:Date �_/ 1 — / //
Job Location ��'/ 1i�FA\/{�4 5 4 � 197i1
Home Owner Address_7�C/jF� �P S. 5�/� , M4 '0tg7�
2
Present Mailing Address J /� ` V �/�� M� (�'���
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 that does not possess a
license, provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s) 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 understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR
CITY OF SM.ETI, ANSSACHUSETTS
u BUILDING DEPARTNIEINT
•3 4y r`N 120 WASHIINGTON STREET, 3'o FLOOR
TEL (978) 745-9595
Rux(978) 740-9846
KI\BEItLEY DRISCOLL
MAYOR Twrtus ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/Bun.DLN G CO\LUISSIONER
Workers' Cornpensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name -(nosiness—O7r/g�aniratiom'Individual): _ eF :
Address: l—/ 645AVPI-tf S 1 1
City/State/Zip: 14(el /1 MA DI?%) Phone It: 7
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ lama sole proprietor or partner- listed on the attached sheet.t 7• ❑ Remodeling
ship and have no employees These sub-contractors have 8. Demolition
working for me in any capacity. workers'comp. insurance. y. Building addition
[No workers'comp, insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.V Electrical repairs or additions
3.;K I am a homeowner doing all work right of exemption per MOL I I.E4 Plumbing repairs or additions
myself. [No workers'comp. C. 152, 91(4),and we have no 12.59 Roof repairs
insurance required.) t employees.[No workers' j3,Q Other
curnp.insurance required.)
•Aqv applicum due checks box al muat also rill out the section baow showing their workers'compensation policy inhumation. -
'I tomaow'w•o who submit this atfldnvii indicating they ate doing all work and then hire oulsido aontraatolx mrml mihmil a new allidavit indicating such.
$'umrxtorx that check this box must anachaf an adcluiunsl shut showing the mate of the subtamrsetors and(heir workers'romp.policy information.
I am an employer that is providing tvorkers'compensation insurance for my entployees. IIeloly is the policy and Job site
infonnution.
Insurance Company Vmne:
Policy p or Self-ins. Lic. n: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline
of up to S25o.00 a day against the violator. lie advised that a copy Of this statement may be furwardcd to the office of
Invcsugwuvts ul'Ihe DIA for insurance coverage verification.
I do hereby Terri corder fhe pu and penulfies of perjury that the information provided above is true and correct.
�t v
P t/ c�: —r N T
OJ/icial use only. Do not wrire in this area,lobe cuntpleted by city or town n/JiriuL
Ciry or fawn: ____.. . _—_ Permitfl.lcense p
Issuing Aulhurity (circle one):
1. Board of Ileallh 2. Building Department 3.C.•ityfrown Clerk 3. Flectrical luspector 5. Plumbing In.speetor
6.Other
Contact
I
CITY OF SuEm) ;tiL1SSACHUSETTS
�! 1 BL=LNC; DEPARTJIENT
130 CV.55HLVGTON STREET, 3*4 FLOOR
• `a;^ T EL (978) 745-9595
F.ux(978) 7-10-9845
IU1tHF_RLEY D2ISCOLL
��+LjYO t TT-{OSCiSST.PIERAS
DIRECTOR OF PI;auc PR0PERTY/8CILDLN<;COSWISSIONEA
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CUR section 111.5
Debris, and the provisions of NtGL c 40, S 54;
Building Permit ik this work shall be is issued with the condition that the debris resulting from
t1I, S ISOA. disposed of in a properly licensed waste disposal facility as defined by tNIGL c
The debris will be transported by:
(name ufhaulur)
"Che tdeb�ris will be
illbe disposed of in
(name of Facility) —
(address of tacility)
s�itat permit applicant
L�te